Implementation Fidelity Research Articles

BackgroundType 2 diabetes (T2D) is a global health concern affecting 10.5% of the adult population and is projected to rise significantly in the coming decades. Lifestyle modification programs, such as the Diabetes Prevention Program (DPP), can effectively reduce T2D risk among individuals with prediabetes. However, their implementation in real-world healthcare settings remains poor, particularly in Spain, where T2D prevalence is the highest in Europe. The ALADIM study aims to evaluate the effectiveness and implementation of an adapted DPP in Spanish Primary Care Centers (PCCs). The primary effectiveness outcome is weight, the co-primary implementation outcome is implementation fidelity. We will also assess the effect of DPP implementation on overall prediabetes management within the PCCs (spillover) by measuring the percentage of people with prediabetes receiving lifestyle advice.MethodsThe ALADIM trial is a hybrid type II effectiveness-implementation cluster-randomized controlled trial involving 10 PCCs of Mallorca (Balearic Islands, Spain). PCCs will be randomized to the intervention (5 PCCs) or control (5 PCCs) group in a 1:1 ratio. The intervention group will receive training and materials to implement and deliver the adapted DPP over 12 months. The control group will continue providing usual care. The DPP will be culturally adapted using the Intervention Mapping-ADAPT (IM-ADAPT) approach. The implementation strategy will be designed using Implementation Mapping. Measures of effectiveness will be assessed at the participant level at baseline, 6 and 12 months during the intervention period, and 18 months after baseline. Implementation outcomes will be assessed at the PCC level at multiple time-points throughout the study period. Spillover will be assessed at PCC level at months -1, 6 and 18. An intention-to-treat analysis will assess effectiveness and spillover effect using generalized estimating equations. Implementation outcomes will be evaluated using a mixed-methods approach.DiscussionThe ALADIM study has the potential to address the gap between research and practice by employing implementation science for evaluation, adaptation and implementation of an evidence-based diabetes intervention. The findings will contribute to the development of a sustainable and scalable implementation strategy for T2D prevention, with potential implications for policy and practice at regional and national levels.Trial registrationClinicalTrials.gov, NCT06871059. Registered 10 March 2025, https://clinicaltrials.gov/study/NCT06871059

In the public sector, evaluation is essential for assessing policy impact, implementation fidelity, and ensuring accountability among policy- and decision-makers. However, little is known about the extent to which evaluation is used to guide policy-making in small-to-medium-sized municipalities. This analysis sought to explore how municipal policy- and decision-makers in the City of Regina view and incorporate evaluation in their work. This qualitative case study used semi-structured interviews with 30 municipal policy- and decision-makers, and analyzed the data using thematic analysis. Our findings suggest that while municipal policy- and decision-makers have attempted to steer the policy development process toward democratic principles, enhanced legitimacy, and evidence-driven practices, there remain substantial barriers to implementing these changes. Key challenges, such as superficial legitimacy and limited resources, were found as obstacles to establishing a comprehensive evaluation framework that support consistent, transparent, and accountable municipal policy-making. Our findings provide valuable insights for those involved in the municipal policy-making process.

Il presente contributo esplora la fedeltà dell'implementazione nella ricerca educativa, evidenziando l'evoluzione del concetto da semplice aderenza a un costrutto multidimensionale. Nel contesto dell'educazione basata su evidenze, la misurazione della fedeltà risulta cruciale per determinare se gli esiti di un inter-vento derivino effettivamente dal programma o da un'implementazione inade-guata. L'analisi affronta la tensione tra fedeltà rigorosa e adattamento conte-stuale, rivelando come concettualizzazioni contemporanee superino questa di-cotomia, riconoscendo che l'adattamento può essere necessario quando preserva i meccanismi centrali dell'intervento. La ricerca empirica suggerisce che livelli moderati di fedeltà possono essere sufficienti per ottenere risultati positivi. Il contributo sottolinea l'importanza di sviluppare interventi con componenti fondamentali chiaramente identificati ma flessibili, promuovendo una compren-sione della fedeltà che bilanci rigore metodologico e sensibilità contestuale

Despite high rates of adolescent mental health problems, there are few effective school-based interventions to address this. Whole-school interventions offer a feasible and sustainable means of promoting mental health, but to date, few have been evaluated. Previously we trialled the Learning Together intervention comprising local needs assessment, student and staff participation in decision-making, restorative practice, and a social and emotional skills curriculum. This was effective not only in preventing bullying (primary outcome) but also in promoting mental well-being and psychological functioning (secondary outcomes). We adapted Learning Together to develop Learning Together for Mental Health, focused on promoting mental health. This paper reports on quantitative data on intervention implementation fidelity, reach and acceptability to assess progression to a Phase III trial. We drew on student baseline and follow-up surveys and an integral process evaluation from a non-randomised feasibility study involving four secondary schools. Southern England. Students in year 8 (age 12/13) at baseline and year 10 (age 14/15) at follow-up and school staff and students and intervention trainers and facilitators completing process evaluation tools. Whole-school intervention featuring student needs assessment, action groups involving staff and students which selected actions from an evidence-based menu, restorative practice to improve relationships and address student behaviour and a social and emotional skills curriculum. Restorative practice training was implemented with fidelity in all schools. Curriculum training was implemented with fidelity in three of four schools. The response rate to the needs survey across the three schools that participated was 79%. Action groups were implemented with fidelity. Action groups at all four schools completed at least one locally decided action and chose at least one action from the menu of evidence-based options. Restorative practice was implemented across all schools. Of lessons that were observed and lessons for which teachers returned logbooks, curriculum delivery was implemented with fidelity. However, two schools delivered 50% or less of the recommended lessons, and not all teachers completed logbooks. All students and staff completing surveys reported finding the Learning Together for Mental Health intervention a good way to promote student mental health. Over a third of students reported definite awareness of actions being undertaken by their schools to improve student mental health. All pre-defined progression criteria to proceed to a Phase III trial were met. The intervention was delivered with good fidelity and had strong acceptability. The schools involved may not be representative of those which we would recruit to a Phase III trial. The study met all pre-determined progression criteria, and the intervention is ready for a Phase III trial with minor adaptations. A Phase III trial of effectiveness is justified. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131594.

Implementation fidelity of video-feedback coaching for communication partners of individuals with congenital deafblindness

Participatory systems approaches are suggested to address the complex drivers of adolescent health but have not been applied or evaluated in a vocational school setting. This study investigated the implementation of a participatory systems approach to health promotion and its potential for driving system-level changes in vocational schools. We used quantitative data to assess implementation fidelity (reach, recruitment, and dose) and outputs in terms of the potential for system-level changes (engagement, knowledge, and leverage points). Qualitative data examined contextual factors (participant responsiveness, and school and municipal contexts) as potential influences on implementation fidelity and outputs. The results showed that school, municipal, and community actors actively participated in systems mapping and in identifying actions targeting leverage points at various system levels. Engaged and knowledgeable community actors were found to be key in generating ideas targeting the deeper layers of the system, enhancing the potential for successful implementation and system-level change. Implementation fidelity and outputs varied across sites due to varying responsiveness and school and municipal contextual factors. In conclusion, participatory systems approaches in vocational schools are feasible, leading to action ideas with promising leverage points for health promotion. However, a flexible approach tailored to specific school and municipal contexts is needed.

Offering evidence-based parenting interventions to caregivers virtually has the potential to increase the reach and public health impact of interventions. As virtual adaptations to evidence-based interventions increase, attention must be paid to implementation fidelity, as high fidelity is associated with better program outcomes. This study examined implementation fidelity of a virtual adaptation of the family-based Guiding Good Choices program delivered to 292 families in primary care in three large healthcare systems during the COVID-19 pandemic. Attendance, dosage, adherence, quality of delivery, and participant engagement were examined quantitatively and qualitatively using interventionist and observer surveys, attendance records, and focus groups with interventionists. Interventionists and observers reported high levels of dosage, adherence, quality of delivery, and participant engagement, but attendance was lower than anticipated. Results suggest that delivering parenting programs virtually in primary care with high fidelity is feasible, but retaining participants may remain challenging in this modality, particularly during a global pandemic.

Growing with Gratitude (GWG) is a universal prevention program based on positive psychology that aims to prevent anxiety and depression in primary-school-aged children. The mental health of children is a key concern for schools as it has an extensive impact in all areas of life. A cluster randomised controlled trial was implemented in nine primary schools (including 27 classes, n = 537 students) in South Australia to evaluate the program. Classrooms were randomly allocated to either a waitlist control or to the GWG program. Students’ anxiety and depression and wellbeing were measured as outcomes at five time points (baseline, mid-program, post-intervention, and 6-month and 12-month follow-up). There were no significant differences for primary or secondary outcomes between the conditions at any time point. Implementation fidelity was poor across the trial. The GWG program did appear to have some impact on children with clinically significant levels of anxiety and depression at baseline. These findings highlight challenges with implementing prevention programs in primary schools and provide suggestions for future research.

Mindfulness-based interventions are increasingly recognized for their positive impact on children’s physical, mental, emotional, and behavioral health. However, no mindfulness-based lifestyle interventions have focused on improving both the physical and mental well-being of economically marginalized preschoolers. Therefore, this one-group study aimed to examine feasibility, acceptability, and satisfaction of a 5-week mindfulness-based lifestyle intervention among preschoolers, caregivers, and childcare teachers. Caregiver-preschooler dyads were recruited from one urban and one rural Head Start childcare center. Outcome data were collected at baseline only, while evaluation data were obtained following the intervention. The intervention included three components: a school-based mindful eating and movement learning for preschoolers; a home-based caregiver training on mindful eating, movement, and parenting; and a school learning and home practice connection in mindfulness. Nineteen preschoolers, 18 caregivers, and three teachers participated. The enrollment rate was 40.4%. Attrition was 0% among preschoolers and 5.6% (n = 1) among caregivers (one caregiver passed away). Baseline data collection completion rate was 100%, with 88.9% (n = 16) caregivers and 84.2% (n = 16) preschoolers having valid ActiGraph data. Hair sample parental consent rate was 57.9% (n = 11), while sample collection rate was 90.9% (n = 10). Intervention implementation fidelity was excellent. Average intervention participation rates were 83.2% (n = 16), 72.2% (n = 13), and 55.6% (n = 10) for the preschooler component, caregiver meeting, and social media-based caregiver component, respectively. Acceptability and satisfaction with the intervention were high among caregivers and teachers. The results support the feasibility, acceptability of, and satisfaction with the 5-week intervention among preschoolers and caregivers from economically marginalized families and childcare teachers.

A field trial of a home-delivered hearing and vision support intervention will assess its impact on the quality of life and well-being of home care recipients with hearing and/or vision impairment and their care partners. This paper outlines the protocol for a process evaluation of the field trial. The process evaluation aims to identify discrepancies between expected and actual outcomes, understand contextual influences, assess implementation fidelity and evaluate the feasibility, appropriateness and acceptability of the intervention. Data will be collected from 87 home care recipients with hearing/vision impairment, their care partner and the sensory therapist who will deliver the intervention at multiple points during the 3-month intervention. Likert-scale ratings for feasibility, appropriateness and acceptability will be gathered. Proxy measures of fidelity, such as intervention session completion rates, will be obtained to ascertain whether the intervention was delivered as designed. Post-intervention, 20% of participants will complete semi-structured interviews to explore contextual and causal factors. Data analysis will include descriptive statistics, regression analysis and thematic qualitative analysis. The process evaluation will elicit the perspectives of home care recipients and their care partners regarding the intervention experience. Older adults with lived experience with dementia and hearing and/or vision will contribute to the proposed research by shaping the interview topic guide to ensure its appropriateness and relevance for the target population. Their insights will result in a more rigorous study and improve the likelihood of the final intervention meeting real-world needs.

ABSTRACT Implementing evidence-based parenting interventions in real-world settings is essential to making effective interventions widely available and improving services and outcomes for children and families. However, little is known about how practitioners experience the implementation of these interventions in the context of child protection services. To address this knowledge gap, we examined the experiences of 10 practitioners implementing the 10-session Standard Triple P parenting intervention with 69 families involved with child protection services in Portugal as part of their routine care practice, of which 34 families completed the intervention and 35 did not. This study aimed to characterize: (1) the level of implementation fidelity (adherence and dosage), (2) how and why intervention modifications are made and their impact on the implementation fidelity, and (3) the practitioners’ perceived barriers and facilitators to implementation in these services. We evaluated fidelity using the Standard Triple P session summary checklists completed by the practitioners at the end of each session. Discussion sessions were conducted with the practitioners to collect data on the intervention modifications and implementation barriers and facilitators. Results showed that Standard Triple P was implemented with high fidelity, with practitioners reporting 96% adherence to intervention content and 76.5% of families attending the full intervention dosage. Additionally, practitioners reported modifications made at the content level and to the format of intervention delivery. Practitioners described the implementation of Standard Triple P in child protection services as shaped by facilitators and barriers at the client, practitioner, process, innovation, organization, and structural levels. They emphasized the need to balance fidelity with modifications to overcome barriers and increase fit with families’ characteristics and needs. Our findings highlight the role of practitioners’ experience in the implementation process and its relevance to inform evidence-based practice with families involved with child protection services.

In recent years, a concerning decline in the physical activity levels of young individuals has been observed, with a notable impact on those with disabilities. Despite evidence suggesting that physical activity programs yield health benefits for youths with disabilities, there exists a significant gap in understanding the specific group-based effects, strategies for effectiveness, sustainability, program development, adaptation details, and empirical value. This systematic review examines quasi-experimental and experimental design research published from 2013 to 2025 on group-based physical activity programs for children, adolescents, and young adults (5-24 years old) with disabilities according to the PRISMA guidelines. The searches yielded 2 715 studies, of which 20 were included. This review highlights multiple disabilities, diverse program durations and activities, and favorable results spanning physical, social, emotional, and cognitive dimensions. The main findings indicated strategies for program effectiveness portrayed as adaptation details. Despite every study providing positive outcomes, limitation concerning confounding variables, sample size and disparity, generalizability, sustainability, and fidelity of implementation remain. Overall, the selected studies suggest great holistic outcomes for youth with disabilities and are to be implemented in addition to special schools or treatment. Future research should explore differences among less common disabilities, emphasizing cognitive outcomes, trainer impact, and program inclusivity to develop accessibility and effective interventions for youth with disabilities.

Abstract As technology becomes a more central support for students with disabilities in inclusive schools, there is a need to understand fidelity of implementation of technology-delivered interventions. We propose a framework for conceptualizing fidelity of the Goal Setting Challenge App, a technology-delivered, intervention based on the Self-Determined Learning Model of Instruction. To develop the fidelity framework, we adopted elements of the standard setting process. Specifically, we created performance level descriptors that describe “good enough” fidelity for three fidelity dimensions: adherence, quality of delivery, and participant responsiveness. Using data from a pilot trial, we present information related to participant responsiveness. We discuss how this could direct future research to support effective adoption of technology-delivered interventions by teachers and schools to advance outcomes.

ABSTRACT A comprehensive change in school culture toward preventive behavioral policies is a complex and time-consuming process. This study examined the implementation of Tier 1 fidelity and sustainability of systemic-level behavior support in the Finnish school context using the ProSchool framework, a Finnish adaption of School-Wide Positive Behavior Interventions and Support. The implementation of the ProSchool framework was studied in 63 schools between 2013 and 2016 (Study 1). The results indicate that schools reached good average implementation fidelity (>80%) after 2–3 years of implementation. Variations in school size and collaboration among staff seem to be related to implementation fidelity. For Study 2, we measured fidelity in a non-random convenience sample of 25 schools 5–10 years after the implementation start (Study 2). Results from the later fidelity measurement implicates that the PBS framework can be adapted and sustained as we found examples of relatively high fidelity in the Finnish school context.

Clinical pathways can improve care and outcomes for children with respiratory illnesses. The Simultaneously Implementing Pathways for Improving Asthma, Pneumonia, and Bronchiolitis Care for Hospitalized Children (SIP) trial is a multicenter, randomized trial of a high-efficiency pathway intervention in general and community hospitals. Our objective was to describe implementation fidelity, strategy use, time costs, barriers, and facilitators. We conducted a mixed-methods study. Hospitals received clinical pathways (intervention) and used 5 implementation strategies: quality improvement (QI) mentor meetings, education, iterative changes, audit and feedback, and clinical decision support via electronic order sets. Data were collected through monthly surveys (11months) of site leaders and recordings of mentor meetings. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using thematic content analysis. Eighteen site leaders (from 18 hospitals) and 8 QI mentors participated. Monthly survey completion rates were 72% to 100%. Pathway implementation fidelity was high (94%). Implementation strategies with the highest use were QI mentor meetings, iterative changes, and electronic order sets. Audit and feedback had the lowest use, driven by information technology challenges and delays in data collection. Implementation time costs were approximately 14hours per month, and data collection had the highest time cost. Implementation barriers included time limitations and stakeholder resistance to change. Facilitators included SIP study resources, engagement of multidisciplinary staff, and alignment with institutional goals. Our multicenter study provides detailed guidance on implementation fidelity, strategy use, time costs, barriers, and facilitators for general and community hospitals implementing high-efficiency pediatric pathway interventions.

ABSTRACTTo promote improved student outcomes, school mental health providers (SMHPs) monitor implementation fidelity when implementing evidence‐based interventions. Current approaches for implementation fidelity monitoring (e.g., intervention checklists) do not account for other relevant implementation indicators best captured through qualitative data. Therefore, this study employed a multi‐faceted approach to monitoring implementation fidelity of the Mental Health Action Plan (MHAP) Program, a school‐based person‐centered care planning program developed to coordinate mental health care at school. The purpose of this mixed methods study was to explore the extent to which the MHAP Program was implemented as intended by describing determinants (i.e., barriers and facilitators) to adherent implementation. Three participant triads (student, caregiver, teacher) and three SMHPs were included in the study. Implementation fidelity checklists and field note data was collected and analyzed using reflexive thematic analysis and descriptive statistics. Qualitative results provided greater context for the quantitative results and elucidated potential adaptations to enhance youth‐intervention fit. Themes related to the caregiver‐child relationship, logistical barriers, student factors, SMHP competing responsibilities, and team dynamics impacted implementation fidelity. Implications for monitoring implementation fidelity of school mental health interventions via qualitative methods as well as study limitations are discussed.

BackgroundImproving quality of sick child care is the primary aim of Integrated Community Case Management services and implementation fidelity is critical to translating an evidence-based intervention to practice. A community-based complex intervention was implemented at the health posts of four agrarian regions of Ethiopia from 2017 to 2018 to improve the coverage and utilization of quality child health services. This study aimed to examine the implementation status of child health care quality improvement interventions in program areas of Oromia region, Ethiopia.MethodsA case study design using quantitative and qualitative research methods was conducted from September to October 2018. Implementation data were collected using observations, document reviews, and program staff interviews. Program staffs including health extension workers and their supervisors were included in surveys, and purposefully selected key informants from health posts to zonal health office level were included in the qualitative component of the research. The analysis framework was focused on the fidelity of the interventions’ content, frequency, duration, and coverage, as well as the potential moderating factors of implementation using the model proposed by Carroll et al. conceptual framework for implementation fidelity.ResultsPerformance Review Clinical Mentoring was implemented according to the plan (every 6 months) in all of the districts and around nine in ten (88%) of the core contents were implemented. Though mentoring was provided by trained mentors, the duration of mentoring was less than the plan to fully implement all of the core activities. Overall, the mentoring program has reached 88% of health extension workers. Slightly greater than three-fourths of health extension workers have been supervised (76%) according to the plan and 80% of health posts were supplied with required iCCM medicines regularly. Staff turnover, topographical challenges, lack of transportation, competing priorities, weak support and feedback from the District health office, and security problems were frequently mentioned challenges to implementation. Whereas, the existence of continual partner support, the presence of integration and coordination of activities, and changes observed were the facilitators of implementation.ConclusionsThe implementation status of the Performance Review Clinical Mentoring Meeting was sufficient, while moderate adherence was observed in supportive supervision and supply of medicines. All of the providers were reached with sick children management training. Therefore, the implementation of community-based interventions should be aware of operational challenges in order to improve and sustain the program’s performance.

This paper investigates the impact of professional development (PD) on teacher performance, emphasizing the correlation between effective teacher training and improved student outcomes. Recognizing teacher quality as a critical determinant of educational success, the study explores how different forms of professional development—ranging from mentoring to workshops and peer collaboration—affect instructional practices. Drawing on national education policies, historical developments, and theoretical frameworks, the paper provides a comprehensive overview of how PD initiatives have evolved and how they are currently assessed. Findings suggest that while professional development has potential to positively influence teaching quality, its effectiveness varies significantly depending on content relevance, delivery mode, and implementation fidelity. Challenges such as insufficient support structures, lack of sustainability, and inconsistent evaluation methods highlight the need for integrated, evidence-based professional learning systems. The study concludes with recommendations for designing impactful PD programs and establishing robust assessment mechanisms to ensure lasting benefits for teachers and students alike. Keywords: Professional Development, Teacher Performance, Educational Reform, Instructional Practice, Teacher Training, Student Achievement.

Abstract The concept of fidelity is important to the implementation of mathematics education innovations. However, viewing fidelity as only adherence to protocols and planned activities may mean that the importance of underpinning causal mechanisms or innovation theory are not attended to fully. To expand and clarify the meaning of fidelity, I consider how the constructs of fidelity and theory are used in implementation methodology, including in mathematics education implementation studies. Alongside consideration of fidelity to implementation design as adherence to planned activity, I propose that fidelity to innovation theory is also important. The construct of fidelity to innovation theory supports assessing whether adaptations in implementation are acceptable or positive. I illustrate how these complementary constructs are applicable depending on the innovation theory, the implementation path characteristics, the fidelity focus, the generative instance, and the actor and activity. The impact sheet to this article is available online at 10.6084/m9.figshare.28722908.

This research aimed to identify the barriers and facilitators in implementation fidelity of malaria screening at Nepal-India border Point of Entry (POE) health desks. A mixed-method approach was used guided by an implementation fidelity framework. Epidemiological records of reported malaria cases at selected border posts of Sudurpaschim and Lumbini province were obtained, while observation of the malaria screening was done among them. Qualitative inquiries were done with the health workers working at selected POEs, health coordinators and development partners working at respective districts, including representatives from three tiers of government: local municipalities, provincial and federal government. The suspected and confirmed migrant population were also interviewed about their experience while seeking for screening facility provided at POEs. Descriptive and trend analysis was done for number of tests per month and total malaria cases identified at POEs, while thematic analysis was performed for qualitative data. There were fluctuating testing trends from March 2021 to December 2022, where malaria screening was peaked before and after rainy season and during festivities and showed its the decreased priorities with the decreasing COVID-19 cases. Over those two consecutive years, 10 malaria cases were identified at POE in two provinces. Adherence to the screening protocol was partially followed, as there were limited guidance for malaria testing protocols at POE, incomplete fulfillment of health declaration forms, non-compliance in providing counseling during testing. Reported unavailability of test kits, variation in eligibility criteria, porosity of border, inadequate health workers, inaccessible infrastructures, limited awareness activities, fear of losing belongings among migrants, and administrative barriers were hindering the screening process. In contrast, presence of well-equipped infrastructures, perceived risk among the migrant's population and regular monitoring during the monthly review meetings at the local health institutionsfacilitated the health workers for conducting screening. The study concluded that prioritizing malaria detection and addressing barriers to ensure fidelity of malaria screening intervention is crucial.