Adaptation and Fidelity: a Recipe Analogy for Achieving Both in Population Scale Implementation.

Balancing adherence to fidelity of evidence-based programs and adaptation to local context is one of the key debates in the adoption and implementation of effective programs. Concern about maintaining fidelity to achieve outcomes can result in replication of research-based models that can be a poor fit with the real world. Equally, unplanned adaptation can result in program drift away from the core elements needed to achieve outcomes. To support implementation of the Maternal Early Childhood Sustained Home-visiting (MECSH) program in multiple sites in three countries, an analogy was developed to identify how both fidelity and adaptation can be managed and successfully achieved. This article presents the Commonsense Cookery Book Basic Plain Cake with Variations recipe analogy to articulate the dual requirements of both fidelity and adaptation to achieve quality implementation of the MECSH program. Components classified by the analogy include identification of core ingredients, methods, and equipment that contribute to fundamental outcomes and fidelity to the evidence-based program, and a planned, collaborative approach to identification of needed variations to suit locally sourced capacity, needs, and tastes. Quality is achieved by identifying and measuring the core ingredients and the variations. Sourcing local ingredients and honoring of context support sustainability of quality practice. Using this analogy has assisted adopters of the MECSH program to understand that effective implementation requires uncompromised commitment to expectations of fidelity to the core components and methods; planned, proactive adaptation; systematic monitoring of both core program and agreed variations; and local ownership and sustainability.