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Background:
Implementation science is shifting from qualifying adaptations as good or bad towards understanding adaptations and their impact. Existing adaptation classification frameworks are largely descriptive (e.g., who made the adaptation) and geared towards researchers. They do not help practitioners in decision-making around adaptations (e.g...
Citations
... We encourage studies to assess and report the impact of adaptations (e.g., instances where an adaptation may help improve acceptability, but may decrease fidelity). Examining adaptations' impact will provide greater insight into how adaptations function, including what adaptations have positive, negative, or neutral impact on both implementation and intervention outcomes (Kirk et al., 2020). ...
Implementing parenting programs in real-world community settings is fundamental to making effective programs widely available and consequently improving the lives of children and their families. Despite the literature acknowledging that the high-quality implementation of parenting programs is particularly challenging in real-world community settings, little is known about how the programs are implemented in these settings. This scoping review followed the methodological framework described by the Joanna Briggs Institute to map evidence on how evidence-based parenting programs have been implemented under real-world conditions. A systematic search of 12 scientific databases, gray literature, and the reference lists of the included studies identified 1918 records, of which 145 were included in the review. Fifty-three parenting programs were identified in studies documenting implementation in real-world community settings worldwide. Most studies included families in psychosocial risk engaged with family-support agencies. The qualitative synthesis identified several implementation outcomes, adaptations, barriers, and facilitators. Most studies reported a maximum of two implementation outcomes, mainly fidelity and acceptability. Providers frequently made adaptations, mainly to bring down barriers and to tailor the program to improve its fit. Findings highlight the need for a more detailed description of the implementation of programs, with greater consistency in terminology, operationalization, and measurement of implementation outcomes across studies. This will promote a more transparent, consistent, and accurate evaluation and reporting of implementation and increase the public health impact of parenting programs. Future studies should also assess the impact of adaptations and the cost-effectiveness and sustainability of programs in real-world community settings.
... The MADI framework refined and synthesized several existing implementation science adaptation and outcome frameworks (e.g., the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). 28,29 Methods This study employs mixed methods with a sequential design. First, we used qualitative evidence to better understand the nature of these adaptations via a semi-structured focus group with clinical staff delivering MISSION to individuals who were chronically homeless. ...
Background: People with co-occurring substance use and mental health disorders (COD) who experience chronic homelessness often have difficulty engaging in treatment and support services. During the Coronavirus Disease 2019 (COVID-19) pandemic this problem was compounded by community agencies reducing or eliminating in-person care to minimize transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study examined the rapid adaptations that were made during COVID-19 to a community-based multicomponent intervention, Maintaining Independence and Sobriety Thorough Systems Integration, Outreach and Networking (MISSION), and how these changes impacted engagement in treatment and fidelity to the intervention prior to and during the COVID-19 pandemic. Methods: Guided by the Model for Adaptation Design and Impact (MADI) framework, this mixed-methods study (1) qualitatively examines the nature of the rapid adaptations made to the MISSION model with n=4 MISSION clinical program staff and (2) quantitatively examines patterns of engagement and fidelity to the MISSION model prior to and during the pandemic among n=109 people with COD who are experiencing chronic homelessness in an urban region of Massachusetts. Results: In consultation with the MISSION developers, clinical staff made rapid innovative adaptations to MISSION. These changes, identified through the qualitative interviews, included developing safe in-person session procedures (e.g., shortening sessions, adapting group sessions to individual sessions) and strategies to engage incarcerated individuals to provide continuity of care (e.g., mailing letters and coordinating with jail staff). Despite the adaptations, adherence to the MISSION model remained consistent during COVID-19 and compared to pre-COVID-19. However, there was more adherence to the structured components of care compared to the unstructured components of care during the pandemic. Interestingly, linkages to other needed treatments and community supports increased by 522% despite the pandemic closures. Conclusions: This mixed-methods study demonstrated that a community-based multicomponent intervention for people experiencing chronic homelessness with COD can be adapted rapidly during a pandemic to help maintain COD treatment and with good fidelity, and that the MADI framework can help document those changes. Thus, these findings provide treatment settings with helpful guidance for community-based COD interventions and public health emergency preparedness.
... Implementation interventions need to balance the need for fidelity with that for adaptation and it has been proposed that these concepts are intrinsically linked [60]. StaRI further specifies that reporting of implementation studies should include fidelity to implementation strategy as planned, and adaptation to suit context and preference [54] and there have been recent frameworks published for the reporting of this [61,62]. It is a prerequisite therefore that there is a clear description of the implementation strategy, core elements and conceptualisation of how adaptation is envisaged. ...
Background
Supported asthma self-management, incorporating an asthma action plan and annual clinical review, has been recommended by UK/global guidelines for over three decades. However, implementation remains poor, as only around a third of individuals receive basic asthma care, according to the UKs leading respiratory charity Asthma and Lung UK. A systematic review of implementation studies recommended that a whole systems approach targeting patients, healthcare professional education, and organisations is needed to improve implementation of supported asthma self-management in primary care. The IMPlementing IMProved Asthma self-management as RouTine (IMP²ART) is a national Hybrid-II implementation cluster randomised controlled trial that aims to evaluate such an approach. This paper describes the development of the implementation strategy for IMP²ART with particular focus on the integration of multiple level theories.
Methods
The Medical Research Council design and evaluation of complex interventions framework and the Person-Based Approach to intervention development were used as guidance for stages of strategy development. Specifically, we (i) set up a multidisciplinary team (including practicing and academic clinicians, health psychologists, public health and patient colleagues), (ii) reviewed and integrated evidence and theory, (iii) developed guiding principles, (iv) developed prototype materials, and (v) conducted a pre-pilot study before final refinement.
Results
The implementation strategy included resources for patients, team-based and individual healthcare professional education, practice audit and feedback, and an asthma review template, as well as a facilitator role accessible to primary care practices for 12 months. The synthesis of the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) and Capability, Opportunity, Motivation and Behaviour (COM-B) frameworks led to an evolved framework bringing together important implementation and behaviour change elements which will be used as a basis for the study process evaluation.
Conclusions
A description of rigorous implementation strategy development for the IMP²ART study is provided along with newly theorised integration of implementation and behaviour change science which may be of benefit to others targeting implementation in primary care.
Trial registration
ISRCTN15448074. Registered on 2nd December 2019.
... EBPs are frequently modi ed to improve their functioning within a given implementation context (Lyon & Bruns, 2019). According to G. , adaptations are intentional modi cations made to EBPs to improve the intervention-implementation context t; whereas modi cations can be planned (e.g., changes made prior to intervention implementation) or reactive (e.g., intentional changes made in response to emergent need based on contextual t of the EBP as delivered; Kirk et al., 2020;Miller et al., 2020). Though EBPs are routinely adapted to maximize t with real-world settings, providers, and patients (e.g., Hall et al., 2016), such adaptations can be reactive in ways aligned more with implementer's personal preferences for EBP use (Stirman et al., 2015) than with the intervention's goal (Cooper et al., 2016), necessitating systematic ways to guide and understand the effectiveness of adaptations made across different phases of implementation. ...
... Next, co-design members re ect on potential impacts of the drafted adaptation(s) by discussing these questions (Kirk et al., 2020): Is this adaptation designed with speci c goals in mind? Is this adaptation aligned with intervention core functions? ...
... MODIFI bridges implementation research and practice by offering a pragmatic and exible method to empower community-based teams to lead this work. MODIFI can be paired with guidance on how to understand and evaluate intervention adaptations (seeKirk et al., 2020), thus allowing teams to engage in cycles of adaptation and evaluation to facilitate implementation of locally-tailored EBPs.MODIFI extends the contributions of other adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Existing adaptation frameworks are largely geared toward researchers and do not provide speci c, feasible techniques. ...
Background. Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.
Method. MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.
Results. In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.
Discussion. MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.
... While implementation scientists have spent considerable time studying intervention fidelity and changes made to interventions, the overwhelming emphasis in this literature has focused on implementer-led adaptations, not reinvention by developers. 36 We see both reinvention and adaptation as vital for the spread of global health reciprocal innovations because of the common desirability of research teams and innovation developers to maintain a degree of control over use of an intervention they created, and wide variance in contextual conditions from country to country. Both types of changes are made by members of cross-national teams. ...
Global health reciprocal innovations originate in low-income and middle-income countries as well as high-income countries before their developers communicate about them with potential adopters in other countries as a transnational team. While communication technology has enabled a more rapid and broader sharing of information about innovations to prevent disease and improve health, innovations of various types have spread among countries, at all levels of income, for many centuries. In this article, we introduce the idea of reciprocal coproduction as a basis for the international sharing of information about innovations that exhibit potential for improving global health. Reciprocal coproduction occurs through two relational team-based processes: developer-led reinvention of an innovation so that it retains its desirable causal effects and implementer-led adaptation of that innovation so that it is compatible with new contexts into which it is introduced. Drawing on research and our own experiences across a range of health issues, we discuss common barriers to reciprocal coproduction and the diffusion of reciprocal innovations. We conclude with lessons drawn from dissemination and implementation science about the effective translation of reciprocal innovations from country to country so that researchers, policy-makers and social entrepreneurs can best ensure equity, accelerate adoptions and heighten the likelihood that global health reciprocal innovations will make a positive difference in health.
... Regarding the analytics, most of the TMFs fell into descriptive frameworks (n = 57; 40%) (e.g., CFIR) [19], 42 (29%) were categorized as prescriptive frameworks (e.g., K2A model) [41], 31 (22%) were identified as diagnostic frameworks (e.g., MADI model) [42], and 13 (9%) were predictive TMFs (e.g., CASCADA theory) [43]. ...
Background
A proliferation of theories, models, and frameworks (TMFs) have been developed in the implementation science field to facilitate the implementation process. The basic features of these TMFs have been identified by several reviews. However, systematic appraisals on the quality of these TMFs are inadequate. To fill this gap, this study aimed to assess the usability, applicability, and testability of the current TMFs in a structured way.
Methods
A scoping review method was employed. Electronic databases were searched to locate English and Chinese articles published between January 2000 and April 2022. Search terms were specific to implementation science. Additionally, hand searches were administered to identify articles from related reviews. Purpose and characteristics such as the type of TMF, analytical level, and observation unit were extracted. Structured appraisal criteria were adapted from Birken et al.’s Theory Comparison and Selection Tool (T-CaST) to conduct an in-depth analysis of the TMFs’ usability, applicability, and testability.
Results
A total of 143 TMFs were included in this analysis. Among them, the most common purpose was to identify barriers and facilitators. Most TMFs applied the descriptive method to summarize the included constructs or the prescriptive method to propose courses of implementation actions. TMFs were mainly mid-range theories built on existing conceptual frameworks or demonstrated grand theories. The usability of the TMFs needs to be improved in terms of the provision of conceptually matched strategies to barriers and facilitators and instructions on the TMFs usage. Regarding the applicability, little attention was paid to the constructs of macro-level context, stages of scale-up and sustainability, and implementation outcomes like feasibility, cost, and penetration. Also, fewer TMFs could propose recommended research and measurement methods to apply the TMFs. Lastly, explicit hypotheses or propositions were lacking in most of the TMFs, and empirical evidence was lacking to support the claimed mechanisms between framework elements in testability.
Conclusions
Common limitations were found in the usability, application, and testability of the current TMFs. The findings of this review could provide insights for developers of TMFs for future theoretical advancements.
... Policy makers, managers, and citizens expect social services (e.g., support for at-risk children and families, individuals with disabilities, and people with substance abuse problems) to provide resources that have been shown to be effective (Escoffery et al., 2019;Kirk et al., 2020;Miller et al., 2020;Morago, 2010;Plath, 2006). However, using evidencebased interventions (EBIs) has been challenging (Bäck et al., 2020;Mosson et al., 2017) because EBIs seldom fit seamlessly into a specific setting (Miller-Day et al., 2013). ...
... The literature offers little guidance for how practitioners should manage fidelity and adaptations. The existing models and frameworks are primarily geared for researchers, guiding coherent description and classification of adaptations (Kirk et al., 2020). A review of adaptation process frameworks identified 13 frameworks that aim to guide translation from a research context to practice. ...
Background
Evidence-based interventions (EBIs) seldom fit seamlessly into a setting and are often adapted. The literature identifies practitioners’ management of fidelity and adaptations as problematic but offers little guidance. This study aimed to investigate practitioners’ perceptions of the feasibility and usability of an intervention aimed to support them in fidelity and adaptation management when working with EBIs.
Methods
The intervention, the adaptation and fidelity tool (A-FiT), was developed based on the literature, along with input from social service practitioners and social services’ Research and Development units’ personnel. The intervention consisted of two workshops where the participants were guided through a five-step process to manage fidelity and adaptations. It was tested in a longitudinal mixed-method intervention study with 103 practitioners from 19 social service units in Stockholm, Sweden. A multimethod data collection was employed, which included interviews at follow-up, questionnaires at baseline and follow-up (readiness for change and self-rated knowledge), workshop evaluation questionnaires (usability and feasibility) after each workshop, and documentation (participants’ notes on worksheets). To analyze the data, qualitative content analysis, Kruskal–Wallis tests, and Wilcoxon rank-sum tests were performed.
Results
Overall, the practitioners had a positive perception of the intervention and perceived it as relevant for fidelity and adaptation management (mean ratings over 7.0 on usability and feasibility). The workshops also provided new knowledge and skills to manage fidelity and adaptations. Furthermore, the intervention provided insights into the practitioners’ understanding about adaptation and fidelity through a more reflective approach.
Conclusion
Practical tools are needed to guide professionals not only to adhere to intervention core elements but also to help them to manage fidelity and adaptation. The proposed A-FiT intervention for practitioners’ management of both fidelity and adaptation is a novel contribution to the implementation literature. Potentially, the next step is an evaluation of the intervention's impact in an experimental design.
... The provision of good-quality social services is a common goal for service providers and decision-makers. Using evidence-based interventions (EBIs) is considered to be one way to achieve this (Escoffery et al., 2019;Kirk et al., 2020;Miller et al., 2020). However, using EBIs in social services has been shown to be challenging (Depanfilis, 2014;Mosson et al., 2016;Bä ck et al., 2020). ...
Using evidence-based interventions (EBIs) is one way to achieve good-quality social services. Adaptations of and efforts to maintain fidelity to EBIs are common. However, research addressing these issues is published across multiple journals. This scoping review aims to explore how fidelity to and adaptations of EBIs are described in the social work literature. We searched for peer-reviewed, English language articles addressing EBIs in social work journals in five databases. Data were extracted and analysed to address the aim of the study. Qualitative content analysis was used to analyse items containing more extensive information. The searches yielded 2,949 articles. The results of 236 articles are presented. Almost fifty different terms were found describing adaptations, and the variety of terms describing fidelity was significantly smaller. Various measures to achieve and/or assess fidelity were identified. The Framework for Reporting Adaptations and Modifications-Expanded was used to categorise information about adaptations. Most adaptations concerned modifications of content and were planned rather than unplanned. Thirty-eight frameworks for implementation of EBIs were identified, and fourteen dealt with fidelity and adaptations. Fidelity and adaptations are increasingly in focus in social work studies. This review contributes to increased knowledge about how fidelity and adaptations have been described in the social work literature.
... FRAME-IS provides a taxonomy of classifying adaptations to implementation support strategies, including what is adapted, the nature of the adaptation, who participated in the adaptation, for whom/what is the adaptation made and when it occurred. Despite the existence of FRAME-IS, adaptations to implementation support strategies are often poorly described [8,10,15,28]. Furthermore, scale-up trials seldom report adaptations in detail, nor do they use consistent taxonomies, instead they rely on scant adaptation descriptions that fail to provide the details required to understand the reasons for potential scale-up penalties [15]. ...
... The adaptation process was informed by the results of the four-step process of the 'PRACTical planning for Implementation and Scale-up' (PRACTIS) guide [33], as well as a scalability assessment [34] using the Intervention Scalability Assessment Tool [31]. Decisions about adaptations were guided by the Model for Adaptation Design and Impact (MADI) decision tree [28]. The process sought to retain the effects of the original intervention by maintaining fidelity consistency to the original implementation support strategies [21], while enabling greater reach (scaling up to ECEC services across three Australian states). ...
... Given that lack of funding is a common barrier to sustainability of public health interventions [41], the introduction of a small fee may be an appropriate strategy for sustainability and feedback from our ECEC partners has confirmed that this membership fee is considered very feasible, relative to other biennial memberships costs. Future efficacy research may consider introducing a small fee for the implementation support strategy, to reduce the number of fidelityinconsistent adaptations required for scale-up [28,33]. ...
Background
Adaptations for scale-up are ubiquitous but are rarely described in detail. Adaptations may be a key reason for the “scale-up penalty” which is when there is a reduction in intervention effect size following scale-up. The Play Active intervention consists of a physical activity policy for early childhood education and care (ECEC) services, with accompanying implementation support strategies. It was first implemented with 81 ECEC services in Perth, Western Australia, in 2021 — with significant positive changes in physical activity practice uptake. The aim of this paper is to describe the extent, type, fidelity consistency, goals, size, scope, and proposed impact of proposed adaptations to the implementation support strategies for scaling-up Play Active.
Methods
Proposed adaptations were defined as planned changes, made prior to making the intervention available. The authors created a list of adaptations from a comparison of the Play Active implementation support strategies, before and after adaptation for proposed statewide availability across Western Australia, Queensland and South Australia, Australia. We used the Framework for Reporting Adaptations and Modifications-Enhanced Implementation Strategies (FRAME-IS) to code adaptations to implementation support strategies. Three authors coded each adaptation and rated their size, scope and proposed impact.
Results
Fifty-three adaptations to Play Active were identified. Most (68%) were proposed for the ‘content’ of implementation strategies, including aspects of their delivery. In practice, this involved changing the delivery mode of implementation support strategies from phone call and email support, to website-based delivery. More than half (56%) of adaptations involved ‘adding elements’ for scale-up. Most adaptations were ‘fidelity consistent’ (95%). The main goals for adaptations were related to ‘increasing the acceptability, appropriateness, or feasibility’ (45%), ‘decreasing the costs’ (19%) and ‘increasing adoption of the evidence-based practice’ (19%). Adaptations were small to medium in size, with most proposed to have a positive (87%) or neutral (8%) effect on the effectiveness of the intervention, rather than negative (4%).
Conclusions
A large number of small, fidelity-consistent, adaptations were proposed for Play Active scale-up. Overall, the process of reporting adaptations was found to be feasible. To understand the impact of these adaptations, it will be important to re-evaluate implementation, effectiveness and process outcomes, at-scale.
... Implementation science frameworks such as the Model for Adaptation Design and Impact (MADI) provide a systematic approach to classify adaptations and their potential impact on patient and implementation outcomes. 19 In this study, we conducted a secondary analysis of a qualitative interview study to evaluate ICU clinicians' experience with adaptations to the practice of prone positioning for ARDS in the setting of COVID-19. Our specific objectives were to understand clinician decisionmaking, attitudes, and uncertainties around practice adaptations to prone positioning for COVID-19 ARDS and to identify areas of ongoing clinical uncertainty regarding how to optimize this lifesaving intervention. ...
... For this we relied on the MADI framework which is organized into three domains (Fig 1). 19 In domain 1, the content of practice adaptations (ie, what was adapted and for whom) are systematically defined. In domain 2, a framework for thinking about the processes of adaptation and how these influence the refined practice is provided. ...
... Although historically understudied in implementation research, several recent advances in understanding adaptation have been made, and they provide a framework for understanding intervention adaptation in real-world settings. 18,19 The analysis for this study was guided by the MADI framework, and it focused mainly on the content of adaptations (domain 1). 19 Future work should assess the processes by which ICU teams make these adaptations (domain 2). ...
BACKGROUND
Prone positioning was widely adopted for use in patients with ARDS from COVID-19. However, proning was also delivered in ways that differed from historical evidence and practice. In implementation research, these changes are referred to as adaptations, and they occur constantly as evidence-based interventions are used in real-world practice. Adaptations can alter the delivered intervention, impacting patient and implementation outcomes.
RESEARCH QUESTION
How have clinicians adapted prone positioning to COVID-19 ARDS, and what uncertainties remain regarding optimal proning use?
STUDY DESIGN AND METHODS
We conducted a qualitative study using semi-structured interviews with ICU clinicians from two hospitals in Baltimore, MD, from February to July 2021. We interviewed physicians (MDs), registered nurses (RNs), respiratory therapists (RTs), advanced practice providers (APPs), and physical therapists (PTs) involved with proning mechanically ventilated patients with COVID-19 ARDS. We used thematic analysis of interviews to classify proning adaptations and clinician uncertainties about best practice for prone positioning.
RESULTS
Forty ICU clinicians (12 MDs, 4 APPs, 12 RNs, 7 RTs, and 5 PTs) were interviewed. Clinicians described several adaptations to the practice of prone positioning, including earlier proning initiation, extended duration of proning sessions, and less use of concomitant neuromuscular blockade. Clinicians expressed uncertainty regarding the optimal timing of initiation and duration of prone positioning. This uncertainty was viewed as a driver of practice variation. Although prescribers intended to use less deep sedation and paralysis in proned patients compared with historical evidence and practice, this raised concerns regarding patient comfort and safety amongst RNs and RTs.
INTERPRETATION
Prone positioning in patients with COVID-19 ARDS has been adapted from historically described practice. Understanding the impact of these adaptations on patient and implementation outcomes and addressing clinician uncertainties are priority areas for future research to optimize the use of prone positioning.
