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Attention to both program fidelity and adaptation
during the complex process of program implementation is critical
to successful, sustained implementation of evidence-based substance
abuse prevention programs.
 —Backer (2002)
When considering feasibility of program implementation, you will
logically begin to consider issues related to program fidelity and
adaptation. Let's say, for example, you find a program that's meets
all of your needs, but you just don't have the money to deliver all of
its required modules. What do you do—shorten the program or raise
more cash? Or, let's say your program-of-choice requires parents
and students to meet separately, but you only have access to a single
meeting room. Would it be so bad to change the curriculum and have
both groups meet together—rather than not use the program at all?
The decisions you make regarding these questions, and others like
them, can have a profound effect on program success. Today's presentation
looks at the differences between program fidelity and adaptation,
the advantages and disadvantages of each, and how you can use the
Feasibility Tool to assess the fidelity of implementation and monitor
changes.
What is Program Fidelity?
According to the Center for Substance Abuse Prevention (2001),
program fidelity is “the degree of fit between the developer-defined
components of a substance abuse prevention program and its actual
implementation in a given organizational or community setting.” Programs
that are implemented with a high level of integrity or fidelity are
delivered with strict adherence to their original design. Programs
that are delivered with high levels of fidelity (i.e., replicated)
are also more likely to achieve their intended outcomes. Any changes
that you make to an evidence-based program may affect its overall
effectiveness.
So why doesn't everyone just do as they're told, follow
directions, and replicate their programs according to plan? Because a
constellation of variables—some mentioned above, others discussed earlier
in this course—often make replication with complete fidelity difficult—and
sometimes impossible. As the Feasibility Tool makes clear, it is often
unreasonable to assume that a program can be replicated if resources
are not available, the target population is saturated with these types
of programs, etc.
The good news is that not all program pieces, or elements,
have the same effect on program outcomes. Analysis shows that certain core
elements are most likely to account for a program's positive outcomes,
and, thus, are most important to replicate. These include the following:
- Program structure. This refers
to the basic design or organization of the intervention, including
the number of sessions, the setting, and key descriptors of the target
population (such as age or primary characteristics). If a program is
designed for middle school students, don't assume it will work as well
with high school students. And before switching the setting from a
school to a community center, consult your program developer to make
sure that doing so won't compromise its effectiveness.
- Content. This refers to the
type of information or skill-building activities included in the program.
Program activities are designed with specific purposes in mind. So,
a program that includes lessons designed to increase students' refusal
skills might not function in the same way if those elements of the
program are changed or eliminated.
- Delivery. This refers to
the method used to transmit the program to the target audience. Some
programs, for example, use peers to deliver some parts of the program,
while others depend entirely on teachers. These decisions were made
for a reason. Altering the method of delivery (e.g., eliminating the
use of peers leaders) might make it more difficult for the target audience
to receive the information provided in the way that it was intended
to be received.
Your priority should always be to replicate with fidelity
an evidence-based program that has been proven effective through rigorous
evaluation. However, when this is impossible, be sure to retain the core
elements of the original evidence-based intervention.
What Is Program Adaptation?
Perhaps the most difficult part of implementing a prevention
program is figuring out if your community can implement the program with
fidelity, or if some degree of adaptation will be necessary. Program
adaptation refers to the deliberate or accidental modification of a program,
including the following:
- Deletions or additions of program components
- Modifications to the existing components
- Changes in the manner or intensity of administration
of program components
- Cultural and other modifications required by local circumstances
If you decide that adaptation is needed, be clear about
the types of program adaptations you plan to make and why. Make sure
that the types and degrees of program adaptations will boost, rather
than detract from, program effectiveness. Before making any changes,
consider the following guidelines:
- Guideline #1. Change your capacity before
changing the program. When there is a less than perfect
fit between program requirements and your organization's capacity
to meet those requirements, it is preferable to build your capacity
rather than modify the program. Why? Because any type of change
you make to a program may potentially compromise its overall effectiveness.
The more adaptations to a program, the less the chance that it
will be as successful as the relevant evaluation study.
So, let's say that the program you have chosen uses intensive,
small-group work as a delivery mechanism, but your staff is inexperienced
in this method. It would be preferable to increase your staff capacity
to lead small groups rather than to transform the program curriculum
into a more didactic model. Similarly, if a program consists of 20
sessions, and it appears that your current financial resources will
only support 15 sessions, it is preferable to seek additional resources
rather than reduce the number of program sessions.
- Guideline #2: Don't mess with the program's
core elements. When you implement a program, remember
that you are more likely to be successful if you maintain the core
elements described above: basic structure, content, and delivery.
If the core elements are not clearly defined, contact the program
developer.
- Guideline #3: Be consistent with evidence-based
prevention principles. If you choose to adapt a program,
you will have a greater likelihood of success if your adaptation
does not violate basic evidence-based prevention principles. For
example, if you choose to adapt a program that contains a peer
leadership component, it is important to retain this element, as
there is considerable evidence of the effectiveness of this approach.
- Guideline #4:
Make sure that your program meets the needs and draws on the assets
of the people you serve. The ultimate goal of program
adaptation is creating a program that respects and responds to
the needs of all members of the target population.
Replication vs. Adaptation
When making decisions about whether to replicate or adapt a
program, bear in mind that neither option is perfect. There will always
be advantages and disadvantages of each approach. Therefore, it is extremely
important that your decision is a conscious and deliberate one—don't
just wait and see how implementation unfolds. It is important to be clear
from the start as to whether you have the capacity and/or desire to implement
your selected program as it was originally designed.
Table 1: Replication vs. Adaptation: Advantages and Disadvantages
As you work to strike the right balance between fidelity and adaptation,
make sure to do so in consultation with program representatives and community
partners. Together, you may be able to find a way to increase your organization's
capacity to meet program requirements so that fewer adaptations are necessary.
Remember, if you do end up altering language or replacing activities
within a program session, make every effort to retain the essence of
the lesson—including the kind of information delivered and the methods
employed. Also, make sure to document any changes that you make. You
can use the Feasibility Tool to do so.
Using the Feasibility Tool to Track Changes
Though most people use the Feasibility Tool during program planning,
you can also use it to monitor implementation. By completing the tool
at set intervals (say, every six months), you can document and describe
changes in capacity over time, the effects of these changes on implementation,
and any subsequent program adaptations.
For example, let's say that you discover during program selection that
you are short a trainer. You note this on the Resources page of the tool
and consider your options: shortening the program or hiring more staff.
Rather than adapting the program, you decide to increase your capacity
and you begin a search to hire another trainer. By the time you review
the tool again, six months later, you have hired the staff you need.
You can record this capacity change on the tool.
You can also use the tool to track adverse changes in capacity. For example,
you may begin your project with strong community support, only to have
it wane over time. This may not be your fault; sometimes, community priorities
shift due to circumstances outside of your control. For example, a child
might be killed by a drunk driver, so the community decides that your
program—which addresses inhalant use—is no longer a priority. It is important
to track changes such as these, which are likely to compromise implementation.
When used in this way, the tool is in effect helping you
conduct a process evaluation. By tracking these changes, you will be
in a better position to explain, why (or why not) your program ultimately
achieved its goals.
Please proceed to Activity
4: To Adapt, or Not to Adapt?
References
Backer, T. E. (2002). Finding the Balance: Program
Fidelity and Adaptation in Substance Abuse Prevention. Rockville
, MD : Substance Abuse and Mental Health Services Administration, Center
for Substance Abuse Prevention.
Center for Substance Abuse Prevention. (2001). Finding
the Balance: Program Fidelity and Adaptation in Substance Abuse Prevention.
Executive Summary of a State of the Art Review. Conference Edition,
June 2001. Rockville, MD: Center for Substance Abuse Prevention.
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