This document summarizes a presentation on frameworks for assessing implementation fidelity of an adaptive dengue prevention strategy replicated in Cuba. It discusses the differences between fidelity (implemented as intended) and adaptation (modifying the intervention), and applies three theoretical frameworks to analyze implementation data. Rebchook et al's framework classified adaptations as positive or negative. Carroll et al's framework assessed adherence across different dimensions. Applying these frameworks revealed specific ways the intervention was adapted, both positively and negatively. The presentation concluded that assessing fidelity prospectively can help correct negative adaptations and determine what components are essential for effectiveness when implementing interventions at large scale. However, standardized methods for evaluating fidelity and operationalizing adaptations are still needed.

1. A reflection on frameworks to assess
implementation fidelity of an adaptive dengue
community-based intervention in Cuba
METHODS FOR IMPLEMENTATION SCIENCE
IN GLOBAL HEALTH
April, 20th. 2017
McGill University
Workshop co-organised by REALISME Chair and McGill of Global Health Programs
Dennis Pérez Chacón
Postdoctoral researcher

2. • FIDELITY = implemented as intended vs. ADAPTATION = bringing changes to it.
• Fidelity ensures effectiveness.
• Adaptation could influence either positively or negatively implementation.
• «Adaptive interventions» = for which adaptations are allowed/encouraged.
• The adequate fidelity-adaptation balance needed for each intervention might
vary.
• Five classical fidelity dimensions to be measured vs. lack of consensus on how to
operationalize adaptations.
• Little research or practical advise on how to adapt an intervention while still
maintaining effectiveness i.e. with fidelity to the components or combination of
components which are prerequisite or essential to reach intended effects.
Context

3. Objectives of the study
• Confronting three theoretical frameworks by assessing implementation fidelity
of an evidence-based empowerment (adaptive) strategy for dengue prevention
replicated in Cuba.
• Drawing lessons on assessing implementation fidelity of adaptive public health
interventions.

4. Method
• Applying Rebchook et al´s:
– Fidelity = implemented as intended. Adaptation = modified, not implemented or
added.
– Qualitative three step assessment: individual & collective by strategy developers and
participatory with key stakeholders.
– Analysis of proceedings and minutes of capacity-building workshops and process
documentation forms that were filled in by implementers from 16 communities, 2004-
2007.
– Data transformation Ql → Qn (Creswell and Clarck, 2011).
• Applying Carroll et al´s & modified Carroll et al´s:
– Carroll et al´s: subcategories of adherence: content, coverage, frequency & duration.
– Modified Carroll et al´s: specific descriptors of fidelity (what, how, how frequently, to
whom, by whom, other descriptors and specifications related to the context) and
specific descriptors of adaptation.
– Reanalysis of empirical implementation data previously collected.

5. Results
Applying Rebchook et al´s. Applying Carroll et al´s. Applying modified Carroll et al´s.
Specific descriptors of adaptation:
Deleting topics (N).
Changing the pedagogical model (N).
Replacing teaching activities (P).
Replacing communities (neither P nor N).
Adding monothematic workshops (P).
P = Positive modification. N = Negative modification.

6. Lessons learned for
implementation
science in global
health
Fidelity & adaptation matter.
Allowed adaptations depends
on the intervention.
Prospective fidelity
assessment will permit to
correct negative adaptations.
Strengths
• Determining the minimum requirements (i.e. essential
components) for high implementation fidelity to ensure
the intended effects in the process of large scale
implementation.
• Discriminating between intervention failure and
implementation failure.
Limits
• A standardized methodology to assess fidelity is not
available yet and proposed measures have been weak
and program-specific.
• Lack of consensus on how to operationalize
adaptations.

7. To go further
• REBCHOOK, M., KEGELES, S., HUEBNER, D. & TRIP RESEARCH TEAM. 2006.
Translating research into practice: the dissemination and initial implementation
of an evidence-based HIV Prevention Program. AIDS Education and Prevention,
18, 119-136.
• CARROLL, C., PATTERSON, M., WOOD, S., BOOTH, A., RICK, J. & BALAIN, S.
2007. A conceptual framework for implementation fidelity. Implementation Science,
2, 20. doi:10.1186/1748-5908-2-40.
• PÉREZ, D., VAN DER STUYFT, P., ZABALA, M. CASTRO, M. & LEFÈVRE, P.
2016. A modified theoretical framework to assess implementation fidelity of
adaptive public health interventions. Implementation Science. 11:91. doi:
10.1186/s13012-016-0457-8.

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