Article
Fidelity Versus Flexibility: Translating Evidence-Based Research into Practice

https://doi.org/10.1016/j.amepre.2008.08.005Get rights and content

Background

Understanding the process by which research is translated into practice is limited. This study sought to examine how interventions change during implementation.

Methods

Data were collected from July 2005 to September 2007. A real-time and cross-case comparison was conducted, examining ten interventions designed to improve health promotion in primary care practices in practice-based research networks. An iterative group process was used to analyze qualitative data (survey data, interviews, site visits, and project diary entries made by grantees approximately every 2 weeks) and to identify intervention adaptations reported during implementation.

Results

All interventions required changes as they were integrated into practice. Modifications differed by project and by practice, and were often unanticipated. Three broad categories of changes were identified and include modifications undertaken to accommodate practices' and patients' circumstances as well as personnel costs. In addition, research teams played a crucial role in fostering intervention uptake through their use of personal influence and by providing motivation, retraining, and instrumental assistance to practices. These efforts by the research teams, although rarely considered an essential component of the intervention, were an active ingredient in successful implementation and translation.

Conclusions

Changes are common when interventions are implemented into practice settings. The translation of evidence into practice will be improved when research design and reporting standards are modified to help quality-improvement teams understand both these adaptations and the effort required to implement interventions in 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

References (68)

  • J. Ovretveit et al.

    Quality collaboratives: lessons from research

    Qual Saf Health Care

    (2002)
  • R.E. Glasgow et al.

    How can we increase translation of research into practice?Types of evidence needed

    Annu Rev Public Health

    (2007)
  • S.D. Horn

    Performance measures and clinical outcomes

    JAMA

    (2006)
  • L.W. Green et al.

    Evaluating the relevance, generalization, and applicability of research: issues in external validation and translation methodology

    Eval Health Prof

    (2006)
  • R.G. Orwin

    Assessing program fidelity in substance abuse health services research

    Addiction

    (2000)
  • B. Resnick et al.

    Treatment fidelity in behavior change research: a case example

    Nurs Res

    (2005)
  • V. Spillane et al.

    Monitoring treatment fidelity in a randomized controlled trial of a complex intervention

    J Adv Nurs

    (2007)
  • C. Carroll et al.

    A conceptual framework for implementation fidelity

    Implement Sci

    (2007)
  • E. Rogers

    Diffiusion of innovations

    (1995)
  • R.E. Glasgow et al.

    The future of health behavior change research: what is needed to improve translation of research into health promotion practice?

    Ann Behav Med

    (2004)
  • J.M. McGinnis et al.

    Actual causes of death in the U.S.

    JAMA

    (1993)
  • E.A. McGlynn et al.

    The quality of health care delivered to adults in the U.S.

    N Engl J Med

    (2003)
  • A.H. Mokdad et al.

    Actual causes of death in the U.S., 2000

    JAMA

    (2000)
  • S.H. Woolf et al.

    Putting it together: finding success in behavior change through integration of services

    Ann Fam Med

    (2005)
  • Integration of health behavior counseling in routine medical care

    (2001)
  • L.A. Green

    The view from 2020: how family practice failed

    Fam Med

    (2001)
  • Treating tobacco use and dependence: a clinical practical guide, 2000

    (2000)
  • Behavioral counseling in primary care to promote healthy diet: recommendations and rationale

    Am J Prev Med

    (2003)
  • Behavioral counseling in primary care to promote physical activity: recommendations and rationale

    Ann Intern Med

    (2002)
  • Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendations and rationale

    Ann Intern Med

    (2004)
  • Crossing the quality chasm: a new health system for the twenty-first century

    (2001)
  • R.E. Glasgow et al.

    Does the chronic care model serve also as a template for improving prevention?

    Milbank Q

    (2001)
  • C.B. Stetler et al.

    The role of formative evaluation in implementation research and the QUERI experience

    J Gen Intern Med

    (2006)
  • D. Cohen et al.

    A practice change model for quality improvement in primary care practice

    J Healthc Manag

    (2004)
  • Cited by (193)

    • Sustaining population benefit using evidence-based public health

      2023, Principles and Application of Evidence-based Public Health Practice
    • Assessing the fidelity of delivery style of a mental skills training programme for young people experiencing homelessness

      2022, Evaluation and Program Planning
      Citation Excerpt :

      The programme was designed to enable flexibility in delivery by having the delivery style as a core active ingredient so that adaptations could be made to meet the needs of programme participants (Harn, Parisi, & Stoolmiller, 2013; Webster-Stratton, Reinke, Herman, & Newcomer, 2011). Ensuring adaptability to changing situations in an evaluation is vital to support data collection when evaluating complex community programmes; there are many factors that cannot be controlled, particularly when programme participants have high need support requirements (Cohen et al., 2008). On a small number of occasions programme participants did not turn up, leading to a session being cancelled, and no observation would take place due to the fixed nature of data collection time points in the pilot study.

    View all citing articles on Scopus
    View full text