Implementation Fidelity Research Articles

The success of information technology policy implementation is influenced by implementation fidelity, which includes compliance, exposure, responsiveness, and system quality. This study examines the level of implementation of the Personnel Management Information System (SIMPEG) at the Education and Culture Office of Central Buton Regency, using this framework. Using a descriptive quantitative survey method, data were collected through questionnaires from SIMPEG users. The results indicate that the SIMPEG implementation is at a moderate level, facing challenges such as inconsistent application of procedures, incomplete user understanding, limited user engagement, and system quality that requires improvement. These findings underscore the need to strengthen human resource capacity, socialisation, and training to ensure effective digital transformation of personnel management. The implementation fidelity approach provides a systematic evaluation framework that helps identify obstacles and opportunities in regional government digitalisation.

Abstract Dissemination and evaluation of the PAX Good Behavior Game (PAX GBG) have produced a body of published and unpublished literature that, if mapped, can provide valuable insights for future expansion and evaluation efforts. Conducting a scoping review of implementation and dissemination studies and gray literature (i.e., “sources”), we aimed to identify (1) implementation strategies being used to support PAX GBG in schools, (2) implementation outcomes assessed across sources, and (3) dissemination strategies being used to promote practice-based implementation of PAX GBG in schools. Our search strategies resulted in 47 sources meeting criteria for full-text extraction. We identified eight implementation strategies: Ongoing consultation/coaching, promoting adaptability (as uniquely defined by each author team), and adaptation of training were the most common. These strategies may be important for future evaluation. Implementation fidelity, implementation quality, and data on coaching sessions (e.g., number/length of sessions) were the most commonly assessed implementation outcomes. However, implementation outcomes were assessed in less than 60% of sources, highlighting the need for feasible methods for documenting such outcomes. The most commonly mentioned dissemination strategies were identifying determinants of innovation uptake, increasing audience skills, funding, and adapting information to context. However, no sources explicitly evaluated the impact of dissemination strategies, underscoring an important direction for future studies.

This study evaluated the use of multi-component coaching for school-based professionals at the building level in facilitating implementation of Prevent-Teach-Reinforce (PTR), a manualized functional behavior assessment and function-based intervention model for students with persistent externalizing behavior. Three school-based professionals (two behavior specialists and one student support staff member) received training to facilitate PTR implementation through a 2-phase multi-component coaching process, which included co-facilitation with researcher followed by independent facilitation with a second dyad. Six teacher-student dyads from three public southeastern U.S. schools participated in this study, with two dyads assigned to each school-based professional. Using a nonconcurrent multiple baseline design across students, the impact of PTR interventions on student behaviors were assessed. Additionally, PTR facilitation fidelity and teacher implementation fidelity were evaluated to discern outcomes of the multi-component coaching process for school-based professionals. Results indicated that school-based professionals facilitated the PTR model with high levels of fidelity, leading to teachers implementing behavior intervention plans with fidelity. Further, student behavior improved when school-based professionals facilitated the PTR model. Social validity assessments with the school-based professionals, teachers, and students indicated that the multicomponent coaching, PTR process, PTR intervention strategies, and their outcomes were acceptable and satisfactory.

Abstract Background Heart failure (HF) is a chronic condition linked to poor outcomes. Since 2016, the European Society of Cardiology recommends a multicomponent care package for the structured follow-up of people with HF. In 2023, the use of patient-reported outcomes (PROs) in cardiovascular care to provide insights into the perspective of patients has been strongly advocated. Guided by the UK Medical Research Council’s framework for complex interventions research, we developed and feasibility tested a multicomponent nurse intervention for multidisciplinary care in HF. There was a need to engage potential intervention users from various practice contexts to inform intervention refinement. Purpose We aimed to achieve agreement on activities of the intervention, and to assess potential barriers for future implementation in HF care, from the perspective of nurses. Methods We used the RAND/UCLA Appropriateness method including a two-round process to reach agreement on the intervention, using a panel of expert nurses with expertise in HF clinical practice. We generated a questionnaire featuring all the 63 activities in the intervention. Panellists rated each activity on a scale of 1 (strongly disagree) to 9 (strongly agree), and re-rated them after the panel discussion. The spread of responses related to each activity was assessed and the median panel rating determined to what extent agreement had been reached. We verbatim transcribed the audiotaped panel meeting discussions in full and coded panellists’ comments for barriers related to the intervention and its delivery in clinical practice. Results The expert panel included 22 expert nurses from Swiss clinical settings admitting people with HF. We conducted two panel meetings, one each for the French speaking and German speaking experts. The number of years of professional experience as a nurse in HF care was 5.7 (mean, SD=3.7) for the French panel; and 10.9 years (mean, SD=9.1) for the German panel. The experts agreed (median ≥7) on 58 activities (out of 63) and disagreed on none. They rated five intervention activities as uncertain. These included the preparation of the intervention, and the clinical use of PRO questionnaires for HF self-care and HF-related health status evaluation to guide care. The qualitative data highlighted that panellists questioned the relevance of HF self-care for people with HF and comorbidities, and remained uncertain about the use of questionnaires during the nurse-patient consultation. As one panellist commented: "I put 6 everywhere in the sense that they make a point but (…), it is abstract (…) using questionnaires in day-to-day work, it’s not yet part of their routine." Conclusion These findings indicate that the intervention is appropriate from the expert nurses’ point of view as regards most intervention activities. Identified barriers including feasibility concerns will help direct intervention implementation fidelity strategies in future research.

Abstract Background Heart failure (HF) is a major public health problem. Decreasing HF societal burden by improving HF care is a priority. Enrolling people in multidisciplinary HF management programmes with self-care strategies are recommended but reports are scarce on complex interventions for HF management programmes and self-care strategies. Purpose We aimed to develop, pilot and evaluate complex interventions for people with HF and their informal caregivers in Switzerland, following the Medical Research Council (MRC) framework for complex interventions research. Methods We formed an academic clinical partnership to initiate the CINACARD research programme, following the MRC framework. This involved problem identification, key stakeholder involvement, systematic identification of evidence and theory, determination of needs, examination of current practice and context, modelling process and outcomes, and intervention operationalisation. Testing comprised evaluating the acceptability and feasibility of delivering and receiving the novel interventions and estimating effect sizes on relevant outcomes. MRC framework key elements included refining the intervention and ensuring patient and public involvement. The development phase included a qualitative study with an interdisciplinary focus group; a national survey on the role of HF nurses; an observational study on the needs of people with HF and their health care utilisation; scoping reviews on symptom perception and frailty in HF. Feasibility testing included a pilot randomized controlled trial and a quasi-experimental study in different settings. The evaluation phase will have an experimental design to evaluate the effectiveness and economic value of a refined complex intervention for people with HF and their informal caregivers. Results CINACARD contains three foci: 1) a multicomponent nurse intervention for multidisciplinary follow-up in HF outpatient care, 2) a complex nursing intervention to support symptom perception in home-based people with HF and their informal caregivers, 3) a complex nursing intervention to address multidimensional frailty in people with HF. Research phases have been conducted for developing and feasibility testing interventions of foci 1 and 2, with both interventions feasible and acceptable for people with HF, informal caregivers and nurses delivering the interventions. The intervention to address frailty in HF is currently being developed. Further actions include international expert guidance, embedded doctoral projects, acquiring research funds, building a research team, translating and culturally adapting patient-reported outcomes, developing teaching modules and ensuring implementation fidelity. Conclusion Ten years research led to detailed and replicable promising interventions. Robust evidence has yet to be produced to contribute to HF care. Transition to the evaluation phase is indicated before implementing tested interventions of the CINACARD programme into HF care.The CINACARD research programme

The current study investigated the effects of direct and indirect instruction on environmental print to enhance Letter Name Knowledge (LNK). The research's foundations were sociocultural (direct) and constructivist (indirect) theories. The study was an eight-week intervention. It took place in the Shinyanga District Council, Tanzania, using a positivist, quantitative approach with a randomised experiment design and no control group. The study included two experimental groups—direct and indirect instruction—across six randomly selected schools from three wards. The participants were public pre-primary children, 293 (162 indirect, 131 indirect) and six teachers (three from each instructional type). The pre-primary teachers were responsible for enhancing LNK during the environmental print intervention, and their work was evaluated using the Fidelity Implementation checklist. The findings indicated insignificant differences in direct and indirect instruction on environmental print on enhancing LNK in both pretest and posttest. Data were collected through intervention tests and observations. Independent samples t-test, Welch t-test, and Kendall's Coefficient of Concordance (W) were used in analysing data. The finding is substantiated by constructivism and sociocultural theory, which suggest that both instructional strategies work better. This perspective supports the idea that both instructions contribute to ensuring that all children, regardless of their background, receive equitable access to quality early literacy education. Improvement in LNK is crucial, as it fosters early reading skills in children, ultimately contributing to equitable quality education, which supports sustainable development goals (4). Recommendation to the Ministry of Education, Science and Technology to develop and provide professional development workshops for pre-primary educators focused on effective strategies for teaching environmental print to enhance letter name knowledge (LNK). Further research needs to be done on pre-primary teachers' views on the challenges and benefits of environmental print strategies. Also, research is needed on the impact of environmental print instruction on children with diverse learning needs and backgrounds.

The K–12 science curriculum emphasizes the development of essential 21st-century skills such as critical problem-solving, environmental literacy, innovation, and effective communication. Despite these curricular priorities, traditional lecture-based instruction often fails to cultivate higher-order thinking—particularly logical reasoning, which is foundational in science learning. This study investigates the effectiveness of Collaborative Game-Based Activities (CGBAs) as an instructional strategy to enhance students’ logical reasoning skills in science. Employing a quasi-experimental research design, the study assessed the quality of CGBA implementation, students’ baseline competency in logical reasoning, their progress across successive CGBA sessions, and overall improvement after the intervention. Grade 9 students participated in a series of CGBA sessions, with their logical reasoning abilities evaluated through pre-test and post-test assessments. Teacher rubric-based evaluations of CGBA quality revealed consistently high implementation fidelity, aligning well with instructional objectives. The findings indicated a significant improvement in students’ logical reasoning scores following CGBA exposure, with the majority advancing from “Satisfactory” to “Good” and “Very Good” performance levels. A paired-samples t-test confirmed this difference to be statistically significant (p < .001), supporting the intervention’s impact on academic performance. The study also affirmed that the assumptions required for parametric testing were met, enhancing the reliability of the findings. Overall, the study underscores the pedagogical value of integrating collaborative and game-based approaches to foster critical thinking, teamwork, and deep engagement with scientific concepts. By transforming passive instruction into active, inquiry-driven learning, CGBA offers a compelling model for strengthening logical reasoning and promoting meaningful science education.

ABSTRACT This article describes a strengths-based intervention and evaluation plan from a multi-institutional effort to identify practices that effectively support Black males in Calculus I at four public universities. The article focuses on ways in which early formative evaluation findings can be used to improve and shape a complex project. Evaluation and intervention plans follow best practices for equitable assessment by capitalizing on existing strengths in Black male college students and by triangulating validated measures including class observations, document review, grades, and changes in content knowledge, sense of belonging, goal orientation, content relevance, self-efficacy, and growth mindset. These measures are used to evaluate early implementation fidelity and to identify student strengths. The intervention and evaluation plans described in this paper can serve as a model for others interested in pursuing strengths-based interventions and evaluations in higher education settings.

Objective This study will assess the feasibility, acceptance, and preliminary efficacy of a novel and engaging task-oriented UE training program, Strength and Power in upper Extremities through Exploratory Driving (SPEED), including joystick-operated ride-on toys, as a therapy adjunct, to advance UE function among children with hemiplegia. Methods We will conduct a randomized controlled trial to compare SPEED training to a dose-matched program, Creative Rehabilitation for Arm Function Training (CRAFT), based on standard-of-care. 30 children with hemiplegia between 3 and 9 years will be recruited. Training will last 6 weeks, 4 times/week, 2 sessions by researchers (30-45 min/session) and 2 sessions by caregivers (15-20 min/session). The SPEED group will engage in playful games including ride-on toys and the CRAFT group will complete seated, fine motor activities. The primary outcome measure is treatment adherence. Secondary measures include participant retention, perceived satisfaction, implementation fidelity scores, child engagement, wrist-worn accelerometry, kinematics, scores on the Shriner’s Hospital Upper Extremity Evaluation, Quality of Upper Extremity Skills Test, and the ABILHAND-Kids questionnaire, grip strength assessment, and measures of navigational control. Impact We propose a community-based, innovative, task-oriented training including modifiedride-on toys to promote self-initiated use of the affected UE in young children with hemiplegia. Study findings have implications for the adoption of the SPEED program by families as an adjunct to conventional therapy to increase children’s functional use of their affected arm through playful exploration.

BackgroundAnemia among women of reproductive age has remained highly prevalent globally. Intravenous (IV) iron is well tolerated and proven effective for treating postpartum iron deficiency anemia in high-income countries, but evidence from LMICs, where oral iron is standard treatment, is limited. The PRIORITY trial will test the effectiveness of IV iron compared to oral iron for postpartum women with moderate anemia in eight LMIC sites. An implementation research (IR) study will be conducted alongside the PRIORITY trial in India and Pakistan to gather information on the intervention characteristics and the implementation process, and to assess feasibility, acceptability, fidelity, and cost of implementation for providing IV iron to postpartum women with moderate iron deficiency anemia.MethodsThe PRIORITY IR study will use a mixed methods convergent parallel design guided by two frameworks: the Consolidated Framework for Implementation Research and Proctor’s implementation outcomes. The IR study will be conducted in the Belagavi, India and Karachi, Pakistan PRIORITY trial sites. Participants will include postpartum women in the IV iron intervention arm of the trial, family members, health workers administering IV iron, hospital administrators, postpartum women who refuse to be part of the trial (Pakistan only), and postpartum women in the oral iron arm of the trial (India only). Data collection methods will include surveys, in-depth interviews, a supervision checklist, and a cost assessment. Survey and supervision checklist data will be analyzed descriptively. Interview data will be analyzed using a directed content analysis approach.DiscussionThe PRIORITY IR study will contribute important information about implementation processes and strategies and feasibility, acceptability, fidelity, and costs for postpartum IV iron implementation. Results of the study can provide guidance for implementing effective anemia treatment in LMIC contexts with a high anemia burden.RegistrationNCT05590260 (21/10/2022),CTRI/2022/10/046632 (19/10/2022),CTRI/2023/05/053302 (31/05/2023).

The Australian aged care workforce faces critical challenges in recruitment, staff retention and workplace well-being. This article explores the potential of integrating Montessori principles into community-based care. A 20-month cohort-controlled study compared participants from a respite service implementing a Montessori-based model of dementia care to ‘care as usual’. Linear mixed modelling assessed group differences in staff burnout, compassion satisfaction and workplace engagement. No significant between-group differences were observed in the rates of change in the variables over time. These findings underscore the need for robust assessment of implementation fidelity and continued evaluation of the capacity of organisation-level Montessori programmes to improve workforce outcomes.

ABSTRACTThe present study is the first systematic review of instructional coaching components, methodologies, and outcomes reported in experimental and quasi‐experimental group design studies examining the impact of coaching for school personnel supporting elementary‐grade students with reading difficulties. Published and unpublished investigations (n = 30) from 2000 to 2023, which included 1863 teachers and interventionists and 21,133 kindergarten through 5‐grade students with reading difficulties, were reviewed. All studies were reviewed using a structured review coding system with four dimensions (i.e., sample characteristics, coaching model elements, methodologies used, and outcomes reported; n = 77 variables). Strengths of reviewed coaching studies were the inclusion of multicomponent professional development with implementation training, diversity in student samples, and the use of statistical testing and reporting of effect sizes. Overall, 27 studies (90%) reported positive improvements in student reading performance at post‐intervention. However, details reported for implementer and student characteristics, professional development components, and reading interventions implemented varied. Weaknesses of the literature were a lack of the following: participant inclusion and exclusion criteria, utilization of coaching in the use of reading screening and diagnostic measures to identify student skill‐specific needs, implementation fidelity measurement, and follow‐up data collection. Implications for research and practice are offered.

This study contributed to a small body of research on empowerment evaluation, viewed here as a social intervention. It examined its processes and principles to determine whether historically conceptualized empowerment and self-determination outcomes resulted from a sample of 131 empowerment evaluations. Objectives included: determining implementation fidelity to each empowerment evaluation model; determining evidence of empowerment evaluation process principles; determining whether empowerment evaluation outcome principles resulted from sample evaluations; and determining whether variation in empowerment and self-determination was explained by interaction between model fidelity and percentage of steps implemented, process principles in evidence, outcome principles in evidence, and evaluator characteristics. Results indicated that, as hypothesized, individual empowerment and self-determination were the likely outcomes of the sample evaluations, that empowerment and self-determination outcomes were more likely when the empowerment evaluations were conducted by female evaluators living and working in an African country, and that a new instrument, Survey on Empowerment Evaluation Practice, Principles, and Outcomes (SEEPPO) was a successful first attempt at assessing the processes, principles, and outcomes of empowerment evaluation work.

Implementation fidelity is critical for the efficient delivery of health services including leprosy services. Healthcare providers are important in monitoring the disease's progression, managing complications, and cross-checking prescribed medications. This study explored implementation fidelity in leprosy care and support for disability prevention and management in Rupandehi district, Nepal. A qualitative case study design was adopted based on implementation research principles. From 25th February to 30th April 2024, data were collected through multiple sources and methods, including key informant interviews, focus group discussions, and observation. Semi-structured interview guidelines and qualitative checklists facilitated the data collection process. Participants were chosen using purposive and selective sampling methods. The data were inductively coded using qualitative analysis software. Thematic analysis was done with codes generated and aggregated to form sub-themes and develop themes. The study revealed that healthcare providers consistently adhered to national leprosy operational guidelines, ensuring sufficient fidelity by prompt multi-drug therapy, case diagnosis, complicated case referral, and regular follow-up. In contrast, poor adherence was demonstrated in the complication management of lepra reactions, ulcer cases, and self-care. The major barriers to leprosy services were financial hardship, complication management, pill burden, drug side effects, and institutional obstacles. In contrast, the facilitators to leprosy services included adequate human resources, treatment supporter's involvement, effective communications, external development partner's role, transportation incentives, and local government support. Healthcare providers demonstrated sufficient adherence to leprosy operational guidelines. While significant gaps were evident in complication management, addressing financial and systematic barriers and leveraging facilitators is essential to strengthening leprosy care and support for disability prevention and management.

BackgroundImplementation fidelity is critical for the efficient delivery of health services including leprosy services. Healthcare providers are important in monitoring the disease’s progression, managing complications, and cross-checking prescribed medications. This study explored implementation fidelity in leprosy care and support for disability prevention and management in Rupandehi district, Nepal.MethodologyA qualitative case study design was adopted based on implementation research principles. From 25th February to 30th April 2024, data were collected through multiple sources and methods, including key informant interviews, focus group discussions, and observation. Semi-structured interview guidelines and qualitative checklists facilitated the data collection process. Participants were chosen using purposive and selective sampling methods. The data were inductively coded using qualitative analysis software. Thematic analysis was done with codes generated and aggregated to form sub-themes and develop themes.ResultsThe study revealed that healthcare providers consistently adhered to national leprosy operational guidelines, ensuring sufficient fidelity by prompt multi-drug therapy, case diagnosis, complicated case referral, and regular follow-up. In contrast, poor adherence was demonstrated in the complication management of lepra reactions, ulcer cases, and self-care. The major barriers to leprosy services were financial hardship, complication management, pill burden, drug side effects, and institutional obstacles. In contrast, the facilitators to leprosy services included adequate human resources, treatment supporter’s involvement, effective communications, external development partner’s role, transportation incentives, and local government support.ConclusionsHealthcare providers demonstrated sufficient adherence to leprosy operational guidelines. While significant gaps were evident in complication management, addressing financial and systematic barriers and leveraging facilitators is essential to strengthening leprosy care and support for disability prevention and management.

This systematic review examines Tier I implementation fidelity in foundational reading skills instruction within K-2 classrooms, focusing on research documented since 2001. The review examined how fidelity was measured, the frequency of its assessment, the facilitators and barriers to its implementation, and the relation to student outcomes. A key finding was that dosage (e.g., frequency or duration of Tier I instruction) was often underreported, which may have impacted conclusions about fidelity and student outcomes. Adherence was universally measured, while other critical components—such as quality of delivery, participant responsiveness, and program differentiation—were inconsistently assessed. The majority of studies relied on either direct observations or teacher self-reports, with only 56% employing both methods, raising concerns about the validity and comparability of fidelity estimates. Fewer than half of the studies examined associations between fidelity and student outcomes, and among those, results were mixed. Facilitators of fidelity included administrative support, structured professional development, and programs with clear lesson structures, while barriers ranged from time constraints and inconsistent monitoring to misalignment with teacher beliefs. These findings highlight the need for more rigorous, standardized measurement tools, ongoing implementation support, and clearer conceptual frameworks to strengthen Tier I instructional fidelity and improve early literacy outcomes.

Abstract Introduction A process evaluation was conducted alongside a multi-site feasibility trial of RecoverED, a multicomponent delirium rehabilitation intervention for older people in post-acute settings. Up to 10 sessions of the home-based intervention is delivered by a multidisciplinary healthcare team. A modified Conceptual Model for Implementation Fidelity was used. Findings on implementation and acceptability are presented. Design and Methods A mixed-methods design was employed, and participants included older adults with delirium, their carers, and trained healthcare professionals (HCPs) from six NHS hospitals in the UK. Adherence to content, dose, and coverage, as well as moderating factors such as recruitment, context, participant responsiveness, delivery quality, and intervention complexity, were assessed. Data included in-depth interviews, focus groups, trial documentation, and training, and supervision logs. Mixed-methods findings were triangulated. Results Nineteen participant-carer pairs were recruited. Five older people, 9 carers, and 8 HCPs were interviewed post-intervention. Seven HCPs participated in two focus groups. Evaluating adherence to content was complex since the intervention is person-centred and personalised. Psychosocial support was delivered more frequently than planned for each individual, while physical rehabilitation and functional recovery activities were delivered less than planned. The value of participant-led goals was emphasised, with high satisfaction, engagement, and perceived value. Implementation was according to the theorised delivery approach, and participants expressed positive views on the quality of delivery. While HCPs found the training comprehensive, they preferred a more interactive and practical format. Teams need to be specifically staffed and co-located for effective coordination and supervision of RecoverED. Most withdrawals (N = 10) were due to complex needs or impairments. No minority ethnic participants were recruited. Conclusion The RecoverED intervention was found to be acceptable; however, recruitment challenges suggest that acceptability and fidelity to dose and coverage should be interpreted with caution. Implementation fidelity to the delivery approach was high and well-perceived.

Promoting regulatory compliance in the face of limited resources poses a distinct challenge to regulators, who can find within rational choice theory a diverse toolkit of policy levers – ones that change the likelihood that noncompliance is sanctioned, the size of sanctions, or the cost of compliance – but must look beyond theory to understand how such levers actually work in practice. In 1999, California introduced changes to its clean water program that modified each of these components, and in the present work we explore the impact of these changes using a mixed-methods approach. While the state’s introduction of $3,000 mandatory minimum penalties for certain Clean Water Act effluent and reporting violations by permitted wastewater facilities reflected a significant step-up in enforcement, the policy also allowed small communities with financial hardship to redirect penalties toward investments in compliance. Our results suggest that the increase in sanctions was associated with decreases in violations with relatively low compliance costs (such as reporting violations), but that there may be considerable mismatch between the scale of penalties and compliance costs for keeping many types of pollutants within regulatory limits, and an underappreciation of critical factors like political pressure that are uncaptured by classical theory. We also find suggestive evidence that penalty conversions reduced pollution limit violations, and highlight tensions between their eligibility criteria and environmental justice. Our case study highlights how policy design and implementation fidelity — how closely a policy is carried out as originally intended — shape regulatory effectiveness and equity, with lessons for regulators and researchers across policy domains.

National Health Service England piloted a low-calorie diet programme, delivered through total diet replacement and behaviour change support via 1 : 1, group or digital delivery, to improve type 2 diabetes in adults with excess weight. To coproduce a qualitative and economic evaluation of the National Health Service low-calorie diet pilot, integrated with National Health Service data to provide an enhanced understanding of the long-term cost-effectiveness, implementation, equity and transferability across broad and diverse populations. What are the theoretical principles, behaviour change components, content and mode of delivery of the programme, and is it delivered with fidelity to National Health Service specifications? What are the service provider, user and National Health Service staff experiences of the programme? Do sociodemographics influence programme access, uptake, compliance and success? What aspects of the service work and what do not work, for whom, in what context and why? Can the programme be improved to enhance patient experience and address inequities? What are the programme delivery costs, and policy implications for wide-spread adoption? A mixed-methods study underpinned by a realist-informed approach was delivered across five work packages, involving: semistructured interviews with service users (n = 67), National Health Service staff (n = 55), service providers (n = 9); 13 service provider focus groups; and service user surveys (n = 719). Findings were triangulated with clinical data from the National Health Service England's first cohort analysis (n = 7540). Fifty-five per cent of service users who started total diet replacement completed the programme and lost an average of 10.3 kg; 32% of those with data available to measure remission achieved it. Examination of programme mobilisation identified barriers around referral equality and the impact of COVID-19, while effective cross-stakeholder working and communication were key facilitators. Service delivery and fidelity assessments identified a drift in implementation fidelity, alongside variation in the behaviour change content across providers. Perceived barriers to programme uptake and engagement aligned across service providers and users, resulting in key learning on: the importance of person-centred care, service user support needs, improvements to total diet replacement and the social and cultural impact of the programme. Early National Health Service quantitative analyses suggest some socioeconomic variation in programme uptake, completion and outcomes. Insights from the evaluation and National Health Service data were combined to develop the programme theory and underpinning context, mechanisms and outcomes. These were used to develop a list of recommendations to improve the cultural competency of programme delivery, total diet replacement delivery, peer support and address psychological support needs. Cost-effectiveness analyses using short-term follow-up data indicated there is potential for the programme to be cost-effective, but not cost saving. The National Health Service low-calorie diet can provide a clinically effective and potentially cost-effective programme to support weight loss and glycaemic control in adults with type 2 diabetes. However, this evaluation identified areas for improvement in referral equity, uptake and completion, and fidelity of delivery, which have informed the development of the programme, which has now been rolled out nationally. Ongoing programme monitoring and long-term follow-up are now required. The real-world setting limited some data collection and analysis. Future work will focus on the analysis of long-term clinical and cost-effectiveness, and addressing inequalities. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132075.

To date, few evidence-based prevention programs (EBP) have been implemented in Germany, despite their growing availability. Some prevention researchers have stated that prevention support systems such as Communities That Care (CTC) could contribute to the wider spread of EBP in Germany and improve the fidelity of EBP implementation. Our study aims to investigate whether CTC leads to greater adoption of EBP in German communities. A quasi-experimental study was conducted with 22 intervention communities (IC) and 22 comparison communities (CC). Data collection occurred at two time points (T0: 2021/2022 and T1: 2023/2024), capturing information on which EBP were implemented in these communities during the prior school year, the number of people reached, and the quality of EBP implementation. Data from 17 IC and 12 CC were included in the final analyses. At T0, there were no significant differences between IC and CC in the number of EBP implemented or the number of people reached. In the IC, the average number of EBP implemented was 3.57 per 10,000 residents at T0, which increased significantly to 8.57 at T1 (p = .004). In the CC, the average number rose from 1.88 at T0 to 3.41 at T1, though this change was not statistically significant (p = .089). Regarding reach, an average of 140 people per 10,000 residents were reached with EBP at T0 in IC, increasing to 407 by T1, while in CC, the average increased from 77 at T0 to 300 at T1. Neither group showed a statistically significant increase in reach. Implementation fidelity remained consistently high in both groups at both time points. The results suggest that CTC may encourage communities to implement more EBP. However, the findings may be influenced by confounding factors and the relatively short observation period. Further research with an extended follow-up is therefore recommended.