Strengthening methods for tracking adaptations and modifications to implementation strategies

Abstract

Background Developing effective implementation strategies requires adequate tracking and reporting on their application. Guidelines exist for defining and reporting on implementation strategy characteristics, but not for describing how strategies are adapted and modified in practice. We built on existing implementation science methods to provide novel methods for tracking strategy modifications. Methods These methods were developed within a stepped-wedge trial of an implementation strategy package designed to help community clinics adopt social determinants of health-related activities: in brief, an ‘Implementation Support Team’ supports clinics through a multi-step process. These methods involve five components: 1) describe planned strategy; 2) track its use; 3) monitor barriers; 4) describe modifications; and 5) identify / describe new strategies. We used the Expert Recommendations for Implementing Change taxonomy to categorize strategies, Proctor et al.’s reporting framework to describe them, the Consolidated Framework for Implementation Research to code barriers / contextual factors necessitating modifications, and elements of the Framework for Reporting Adaptations and Modifications-Enhanced to describe strategy modifications. Results We present three examples of the use of these methods: 1) modifications made to a facilitation-focused strategy (clinics reported that certain meetings were too frequent, so their frequency was reduced in subsequent wedges); 2) a clinic-level strategy addition which involved connecting one study clinic seeking help with community health worker-related workflows to another that already had such a workflow in place; 3) a study-level strategy addition which involved providing assistance in overcoming previously encountered (rather than de novo) challenges. Conclusions These methods for tracking modifications made to implementation strategies build on existing methods, frameworks, and guidelines; however, as none of these were a perfect fit, we made additions to several frameworks as indicated, and used certain frameworks’ components selectively. While these methods are time-intensive, and more work is needed to streamline them, they are among the first such methods presented to implementation science. As such, they may be used in research on assessing effective strategy modifications and for replication and scale-up of effective strategies. We present these methods to guide others seeking to document implementation strategies and modifications to their studies. Trial registration clinicaltrials.gov ID: NCT03607617 (first posted 31/07/2018).

The case for prioritizing implementation strategy fidelity measurement: benefits and challenges

“…The authors utilize several implementation frameworks to specify implementation strategies, describe implementation barriers, and the modifications to strategies used to overcome them. They ultimately describe several adaptations including (1) the reduced frequency of peer support meetings, (2) additional information sharing between study clinics, and (3) additional items included in a data collection tool [ 40 ]. Adaptations of implementation strategy fidelity assessment could include (1) participant responsiveness to the new frequency of peer support meetings, (2) the receipt and additional content of the new information shared between study clinics, and (3) the receipt and content of the new questions added to the data collection tool.…”

A Modified Implementation Mapping Methodology for Evaluating and Learning From Existing Implementation

“…This necessitates the use of insights gained through step (1) and (2) and allows for rating already employed strategies in terms of their fit with previously identified implementation determinants. For this purpose, both the CFIR-ERIC matching tool ( 19 ) and Haley et al's ( 20 ) description of methods for tracking modifications to employed implementation strategies can be helpful resources. As a result of these discussions, employed implementation strategies may be adapted, discontinued, expanded, or replaced by new strategies deemed to better support the achievement of intervention and implementation outcomes.…”

Implementation mapping to plan for a hybrid trial testing the effectiveness and implementation of a behavioral intervention for HIV medication adherence and care retention

“…Our implementation blueprint facilitated more comprehensive planning for the trial, and we can now formally and prospectively track what strategies were planned in advance vs. modified in reaction to unanticipated barriers that arose in clinics during implementation ( 37 ). We will then describe how and why strategies succeeded (or failed) so they can be replicated or further refined in future implementation efforts ( 42 ). Our process thus far has yielded knowledge generalizable to other behaviorally informed EBPs for HIV/AIDS.…”