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

Abstract

Implementation strategies are systematic approaches to improve the uptake and sustainability of evidence-based interventions. They frequently focus on changing provider behavior through the provision of interventions such as training, coaching, and audit-and-feedback. Implementation strategies often impact intermediate behavioral outcomes like provider guideline adherence, in turn improving patient outcomes. Fidelity of implementation strategy delivery is defined as the extent to which an implementation strategy is carried out as it was designed. Implementation strategy fidelity measurement is under-developed and under-reported, with the quality of reporting decreasing over time. Benefits of fidelity measurement include the exploration of the extent to which observed effects are moderated by fidelity, and critical information about Type-III research errors, or the likelihood that null findings result from implementation strategy fidelity failure. Reviews of implementation strategy efficacy often report wide variation across studies, commonly calling for increased implementation strategy fidelity measurement to help explain variations. Despite the methodological benefits of rigorous fidelity measurement, implementation researchers face multi-level challenges and complexities. Challenges include the measurement of a complex variable, multiple data collection modalities with varying precision and costs, and the need for fidelity measurement to change in-step with adaptations. In this position paper, we weigh these costs and benefits and ultimately contend that implementation strategy fidelity measurement and reporting should be improved in trials of implementation strategies. We offer pragmatic solutions for researchers to make immediate improvements like the use of mixed methods or innovative data collection and analysis techniques, the inclusion of implementation strategy fidelity assessment in reporting guidelines, and the staged development of fidelity tools across the evolution of an implementation strategy. We also call for additional research into the barriers and facilitators of implementation strategy fidelity measurement to further clarify the best path forward.

Examining the complementarity between the ERIC compilation of implementation strategies and the behaviour change technique taxonomy: a qualitative analysis

“…Alternatively, designers using the behaviour change wheel approach to intervention design could refer to the ERIC compilation to see how certain intervention functions or BCTs could be operationalised in an implementation context. Second, the results could also inform fidelity assessment by suggesting observable BCTs that could be monitored as strategies are deployed [50,51]. Finally, each taxonomy can make a unique contribution that can be leveraged to enhance the reporting, replication, and synthesis of strategies.…”

Fidelity to the ACT SMART Toolkit: an instrumental case study of implementation strategy fidelity

“…Moreover, the potential issues with measurement may have been compounded by the fact that standard measures were not used for dose and participant responsiveness. However, as an emerging field, implementation science often faces issues related to measurement and standardized measures specific to implementation strategy fidelity have not yet been developed [ 49 , 50 , 60 ]. Researchers have developed some standard measures for intervention fidelity, and these may be able to be adapted to assess implementation strategy fidelity in the future [ 61 ].…”

“…Of course, this is contingent upon an ability to determine whether implementation of the strategy remained consistent with its underlying theory [ 47 , 48 ]. Notably, increasing understanding about how implementation strategies work has been identified as a research priority within the field of dissemination and implementation science [ 49 – 51 ].…”

Study protocol for a cluster-randomized trial of a bundle of implementation support strategies to improve the fidelity of implementation of schoolwide Positive Behavioral Interventions and Supports in rural schools

“…Process measures include interviews with school coaches and principals, and tracking logs and reflections from the project's implementation support practitioners, to assess dose of the RS3 implementation support strategies and fidelity to the RS3 approach [ 69 , 70 ].…”