American Journal of Preventive Medicine
ArticleFidelity Versus Flexibility: Translating Evidence-Based Research into Practice
Introduction
Difficulties exist in developing, documenting, and reproducing complex interventions, such as those directed toward healthcare professionals to improve clinical care.1 Implementation is the means by which evidence-based clinical research is translated into practice.2, 3 However, few studies describe the process of implementing change in healthcare settings,4, 5 and, as a result, little is known about how to translate good ideas and evidence into practice.6, 7, 8
Treatment fidelity, or the degree to which an intervention maintains its original form, is fundamental to the implementation of complex interventions and effectiveness research.2, 9, 10, 11, 12, 13 In efficacy studies, adherence to intervention protocols is carefully monitored. But in effectiveness studies, where interventions are tested in real-world practice settings, adherence is more challenging. This has serious implications for evaluating study results. Currently, there are two views about how to manage treatment fidelity in effectiveness research.2 One view is that strict adherence to program protocol is necessary under all circumstances.9, 12 A second view is that adaptation is necessary, but must be done cautiously to avoid compromising validity. In this latter view, fidelity refers to maintaining adherence to key intervention components while other modifications, particularly those that help the integration of the intervention into the practice, are encouraged.3, 14, 15
Little is known about the kinds of changes made to behavioral interventions as they are translated into medical practice. This article addresses the question What type of issues prompt changes to interventions during the implementation process in primary care settings? and aims to open the black box of implementation by exploring the tension between treatment fidelity and flexibility in practice-based health promotion research.
Section snippets
Methods
Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks was an initiative funded by the Robert Wood Johnson Foundation (RWJF) in collaboration with the Agency for Healthcare Research and Quality (AHRQ) in response to a growing body of scientific evidence recognizing the importance of lifestyle on health and well-being, and acknowledging the potential role that primary care clinicians can play in preventing morbidity and mortality through counseling and other
Results
All Prescription for Health interventions changed as they were integrated into practice. Table 3 describes each project's essential intervention components and the changes that occurred during implementation. While all interventions eventually stopped changing, what the intervention was at stasis was often different from what had been proposed in the grant application. The one apparent exception to this rule was Project 8, which reported no changes to the proposed intervention. However, this
Discussion
Effectiveness research is a messy process.48, 49 All Prescription for Health interventions arrived at stasis, but during implementation, research teams worked with practice members to tinker with interventions, adapting them to fit local circumstances. The need to adapt does not indicate a poor intervention or an inexperienced research team; it is a common part of the research process. It is the journey of translating evidence-based research into practice.48
Multiple reasons have been identified
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