Can systematic implementation support improve programme fidelity by improving care providers' perceptions of implementation factors? A cluster randomized trial

Abstract

Background: Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support.

Methods: Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis.

Results: Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028).

Conclusions: Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices.

Trial registration: ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).

Keywords: Implementation; Implementation outcomes; Implementation process; Mental health; Readiness.

Conflict of interest statement

Torleif Ruud and is an Editorial Board Member for BMC Health Services Research. The authors declare that they have no conflicts of interest. The IPAT questionnaire can be used free of charge.

© 2022. The Author(s).

Figures

Fig. 1

Description of the intervention: The structured implementation support included a set of interventions, here displayed on a timeline to show when and how long each intervention was provided for each of the four practices (IMR Illness Management and Recovery practice, FAM Family supportive practice, MED Antipsychotic medication, PHYS Physical health support)

Fig. 2

Flow diagram displaying the sample and exclusion during the 18-months period. *Clinical units were excluded for not meeting the inclusion criteria of a minimum of three responders on the IPAT questionnaire

Fig. 3

Correlations between the Implementation Process Assessment Tool score and fidelity score for the intervention and control groups every sixth month. Linear mixed model analysis model with time adjusted IPAT score as fixed effect and type of practice as random effect

Fig. 4

Comparison of IPAT scores between the intervention and control groups, adjusted for time and practice implemented, using a linear mixed model. Means and standard deviations (SD) are displayed in the figure (orange for intervention and blue for control group)