DELIVERING INTERVENTIONS
6.5 FIDELITY—ADAPTATION DEBATE
as part of process evaluation. Process evaluation (Chapter 13) aims at understanding how the intervention is given, what influences its implementation, and the capacity of the intervention to initiate its mechanism of action.
6.5 FIDELITY—ADAPTATION DEBATE
Despite efforts to promote fidelity (i.e. development of intervention manuals and training of providers), evidence clearly demonstrates variations in intervention delivery in research (e.g. Kyle et al., 2015; Toomey et al., 2019) and in practice (e.g.
Brose et al., 2015; Cunningham & Card, 2014). In practice, variations and in particular adaptations of interventions are the rule rather than the exception (Pérez et al., 2016).
Asking health professionals to strictly follow the intervention manual has been a challenge, with the potential of poor fidelity. Health professionals express resent- ment toward strictly adhering to the protocol when delivering interventions, and toward the implementation of standardized interventions. They believe that strict adherence leads to deterioration in the rapport, therapeutic relationship, or working alliance between interventionists and clients (Mignogna et al., 2018; Wallace & von Ranson, 2011). Yet, this relationship is emerging as a significant determinant of cli- ents’ engagement and enactment of the intervention, and subsequently experience of improvement in the outcomes (e.g. Webb et al., 2010). Health professionals believe in the importance of adapting or tailoring the intervention to clients’ needs, character- istics, and life circumstances, as well as to clients’ initial response to the intervention, for achieving successful outcomes. Interventionists’ and health professionals’ beliefs and attitudes have been found to affect the fidelity with which they deliver health interventions (e.g. Barber et al., 2007; Wang et al., 2015).
The debate between the importance of delivering interventions with fidelity and the perceived necessity of tailoring interventions could account for the reported high prevalence of adaptations in intervention delivery. Adaptations are often done for standardized interventions (DeRosier, 2019). Adaptations can be deliberate/
intentional or accidental/unintentional (Pérez et al., 2016). Their aim is to increase the relevance and applicability of standardized interventions to the characteristics of clients who receive it and/or to the features of the context in which the interventions are given. As such, adaptations are justified and sometimes desirable: They enhance the uptake of the intervention; improve the appropriateness or quality of its delivery by interventionists; and increase the intervention’s acceptability, engagement, and enactment by clients, all of which contribute to the intervention’s effectiveness (Wainer & Ingersoll, 2013; DeRosier, 2019; Mauricio et al., 2019). However, to achieve their potential benefits, adaptations should be carefully conceptualized within the parameters of the intervention theory and clearly delineated in the intervention protocol and manual that guides intervention delivery (Homel et al., 2019; Lewis et al., 2019).
The adaptation of health interventions should follow a systematic process during which the intervention designers or developers, health professionals, and clients col- laborate to identify what needs to be modified, why and how; to specify the principles of adaptation; and to revise the intervention manual accordingly. Basically, the pro- cess of adaptation consists of group sessions that involve: (1) presentation of the intervention theory, to contextualize the discussion; (2) description of one interven- tion component; (3) delineation of how the component reflects the respective inter- vention’s active ingredient and contributes to the desired changes; (4) identification of the resources needed to apply the component; (5) clarification, as needed, of any
aspect of the component and its delivery; (6) discussion of the participants’ overall perspective on the component as well as on aspects of the component that may not fit the needs or characteristics of the clients or the features of the implementation context—the discussion explores the reasons for the perceived misfit and ways to modify the aspects to improve the intervention’s fit, without significantly altering the respective active ingredient; (7) repeating steps 2–6 for each component comprising the intervention; (8) review of the proposed adaptations and generation of clear prin- ciples and guidelines for what adaptation can be made, how, when, for what clients, and in what contexts. These principles and guidelines are incorporated in the inter- vention protocol and manual as suggested by Lewis et al. (2019).
Variants of this systematic process are described for the (1) the cultural adaptation of health interventions (e.g. Sidani et al., 2017), including the behavioral therapies for insomnia (Sidani et al., 2018); and (2) adaptation of interventions to the local target client population and context (e.g. Aarons et al., 2012; Cabassa et al., 2011, 2014;
Fox et al., 2019).
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C H A P T E R 7
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© 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.
C H A P T E R 7
Development of Intervention Manual
Development of an intervention manual is one strategy that is foundational for pro- moting the fidelity with which a health intervention is delivered in research and practice. Although the terms protocol and manual are often used interchangeably in the literature, they may differ in the level of detail they offer in providing guidance for delivering an intervention. Just like the research design, operationalized in the study protocol, is the blueprint for conducting a study, the intervention protocol is the overall plan for providing the intervention. The protocol gives an overview of the intervention components and lists the topics and activities planned for each interven- tion session or module. Just like the procedure book or standards available for health professionals in practice, the intervention manual is a structured procedural text that outlines the rationale, goals, and content of an intervention, and details the tech- niques or actions for administering the intervention (Brose et al., 2015; Lorencatto et al., 2013). The manual is a document that describes the theoretical underpinning of the intervention and specifies what exactly is done, how, where, and when to deliver the intervention. Thus, the manual clarifies the logistics for providing the intervention as designed.
The procedural information presented in a manual differs with the format of health interventions. For standardized health interventions delivered by interventionists in face-to-face or distance format, the manual is available as a book or document that describes the step-by-step procedure for carrying out the activities planned for each session and includes scripts for conveying core content. For technology-based delivery of health interventions, the manual is reflected in the content and other material (e.g. video presentation, exercises) comprising each module. For tailored health inter- ventions, the manual describes the decision rules that interventionists should follow in applying the customization algorithm or that are embedded in the delivery of technology-based adaptive interventions.
In this chapter, the approach for developing a manual is described. The content covered in the manual is specified and illustrated with examples. The potential use of the manual in research and practice is discussed.
7.1 Approach for Developing the Intervention Manual