BackgroundOne of the major debates in implementation research turns around fidelity and adaptation. Fidelity is the degree to which an intervention is implemented as intended by its developers. It is meant to ensure that the intervention maintains its intended effects. Adaptation is the process of implementers or users bringing changes to the original design of an intervention. Depending on the nature of the modifications brought, adaptation could either be potentially positive or could carry the risk of threatening the theoretical basis of the intervention, resulting in a negative effect on expected outcomes. Adaptive interventions are those for which adaptation is allowed or even encouraged. Classical fidelity dimensions and conceptual frameworks do not address the issue of how to adapt an intervention while still maintaining its effectiveness.DiscussionWe support the idea that fidelity and adaptation co-exist and that adaptations can impact either positively or negatively on the intervention’s effectiveness. For adaptive interventions, research should answer the question how an adequate fidelity-adaptation balance can be reached. One way to address this issue is by looking systematically at the aspects of an intervention that are being adapted. We conducted fidelity research on the implementation of an empowerment strategy for dengue prevention in Cuba. In view of the adaptive nature of the strategy, we anticipated that the classical fidelity dimensions would be of limited use for assessing adaptations. The typology we used in the assessment—implemented, not-implemented, modified, or added components of the strategy—also had limitations. It did not allow us to answer the question which of the modifications introduced in the strategy contributed to or distracted from outcomes. We confronted our empirical research with existing literature on fidelity, and as a result, considered that the framework for implementation fidelity proposed by Carroll et al. in 2007 could potentially meet our concerns. We propose modifications to the framework to assess both fidelity and adaptation.SummaryThe modified Carroll et al.’s framework we propose may permit a comprehensive assessment of the implementation fidelity-adaptation balance required when implementing adaptive interventions, but more empirical research is needed to validate it.

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In global health, researchers and decision makers, many of whom have medical, epidemiology or biostatistics background, are increasingly interested in evaluating the implementation of health interventions. Implementation science, particularly for the study of public policies, has existed since at least the 1930s. This science makes compelling use of explicit theories and analytic frameworks that ensure research quality and rigour. Our objective is to inform researchers and decision makers who are not familiar with this research branch about these theories and analytic frameworks. We define four models of causation used in implementation science: intervention theory, frameworks, middle-range theory and grand theory. We then explain how scientists apply these models for three main implementation studies: fidelity assessment, process evaluation and complex evaluation. For each study, we provide concrete examples from research in Cuba and Africa to better understand the implementation of health interventions in global health context. Global health researchers and decision makers with a quantitative background will not become implementation scientists after reading this article. However, we believe they will be more aware of the need for rigorous implementation evaluations of global health interventions, alongside impact evaluations, and in collaboration with social scientists.

Summarybackground The 55th World Health Assembly declared dengue prevention and control a priority and urged Member States to develop sustainable intersectoral strategies to this end. To provide evidence for the reorientation of the dengue prevention policy in Cuba, we launched an intervention study to document the effectiveness of a local-level intersectoral approach.methods We used a quasi-experimental design. Social scientists introduced participatory methods to facilitate dialogue in the biweekly meetings of the intersectoral Health Council of the intervention area. This council subsequently developed an intersectoral plan for dengue prevention, of which the core objective was to design and implement activities for communication and social mobilization. In the control area, routine dengue control activities continued without additional input. Knowledge, attitudes and perceptions of dengue, and entomological indices were compared inside and between the areas before and after the 1-year intervention period.

The reemergence of dengue as an important public health problem reflects the difficulties in sustaining vertically organized, effective, control programs and the need for community-based strategies for Aedes aegypti control that result in behavioral change. We aimed to disentangle the relationships between underlying determinants of dengue related practices. We conducted a cross-sectional study in 780 households in La Lisa, Havana, Cuba. A questionnaire and an observation guide were administrated to collect information on variables related to economic status, knowledge on dengue, risk perception and practices associated with Aedes aegypti breading sites. To test a conceptual model that hypothesized direct relationships among all these constructs, we first used Exploratory Factor Analysis with Principal Component Analysis to establish the relationship between observed variables and the underlying latent variables. Subsequently, we tested whether the observed data supported the conceptual model through Confirmatory Factor Analysis. Exploratory Factor Analysis indicated that the items measured could be reduced into five factors with an eigenvalue >1.0: Knowledge on dengue, Intradomiciliar risk practices, Peridomiciliar risk practices, Risk perception and Economic status. The proportion of the total variance in the data explained by these five factors was 74.3%. The Confirmatory Factor Analysis model differed from our hypothesized conceptual model. Only Knowledge on dengue had a significant, direct, positive, effect on Practices. There was also a direct association of Economic status with Knowledge on dengue, but not with Risk perception and Practices. Clarifying the relationship between direct and indirect determinants of dengue related practices contributes to a better understanding of the potential effect of Information Education and Communication on practices and on the reduction of Aedes aegypti breeding sites and provides inputs for designing a community based strategy for dengue control.