Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, PO Box 196, 9700, AD, Groningen, The Netherlands.
Department of Rehabilitation Medicine, Center for Rehabilitation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
Implement Sci. 2017 Dec 1;12(1):143. doi: 10.1186/s13012-017-0667-8.
Although the importance of evaluating implementation fidelity is acknowledged, little is known about heterogeneity in fidelity over time. This study aims to generate insight into the heterogeneity in implementation fidelity trajectories of a health promotion program in multidisciplinary settings and the relationship with changes in patients' health behavior.
This study used longitudinal data from the nationwide implementation of an evidence-informed physical activity promotion program in Dutch rehabilitation care. Fidelity scores were calculated based on annual surveys filled in by involved professionals (n = ± 70). Higher fidelity scores indicate a more complete implementation of the program's core components. A hierarchical cluster analysis was conducted on the implementation fidelity scores of 17 organizations at three different time points. Quantitative and qualitative data were used to explore organizational and professional differences between identified trajectories. Regression analyses were conducted to determine differences in patient outcomes.
Three trajectories were identified as the following: 'stable high fidelity' (n = 9), 'moderate and improving fidelity' (n = 6), and 'unstable fidelity' (n = 2). The stable high fidelity organizations were generally smaller, started earlier, and implemented the program in a more structured way compared to moderate and improving fidelity organizations. At the implementation period's start and end, support from physicians and physiotherapists, professionals' appreciation, and program compatibility were rated more positively by professionals working in stable high fidelity organizations as compared to the moderate and improving fidelity organizations (p < .05). Qualitative data showed that the stable high fidelity organizations had often an explicit vision and strategy about the implementation of the program. Intriguingly, the trajectories were not associated with patients' self-reported physical activity outcomes (adjusted model β = - 651.6, t(613) = - 1032, p = .303).
Differences in organizational-level implementation fidelity trajectories did not result in outcome differences at patient-level. This suggests that an effective implementation fidelity trajectory is contingent on the local organization's conditions. More specifically, achieving stable high implementation fidelity required the management of tensions: realizing a localized change vision, while safeguarding the program's standardized core components and engaging the scarce physicians throughout the process. When scaling up evidence-informed health promotion programs, we propose to tailor the management of implementation tensions to local organizations' starting position, size, and circumstances.
The Netherlands National Trial Register NTR3961 . Registered 18 April 2013.
尽管评估实施保真度的重要性已得到认可，但对于保真度随时间的变化的异质性知之甚少。本研究旨在深入了解多学科环境中健康促进计划实施保真度轨迹的异质性，以及与患者健康行为变化的关系。
本研究使用了一项全国范围内实施基于证据的体育活动促进计划的纵向数据，该计划在荷兰康复护理中实施。保真度得分是根据参与专业人员每年填写的调查计算得出的（n=±70）。较高的保真度分数表示更完整地实施了计划的核心组成部分。对 17 个组织在三个不同时间点的实施保真度得分进行了层次聚类分析。使用定量和定性数据来探索确定轨迹之间的组织和专业差异。进行回归分析以确定患者结果的差异。
确定了三个轨迹，分别是：“稳定高保真度”（n=9）、“适度且不断提高的保真度”（n=6）和“不稳定的保真度”（n=2）。与适度和不断提高的保真度组织相比，稳定高保真度组织通常规模较小、开始较早且以更结构化的方式实施该计划。在实施期的开始和结束时，与适度和不断提高的保真度组织相比，在稳定高保真度组织中工作的专业人员对医生和物理治疗师的支持、专业人员的赞赏以及对计划的兼容性的评价更高（p<.05）。定性数据显示，稳定高保真度组织通常对该计划的实施有明确的愿景和策略。有趣的是，这些轨迹与患者自我报告的体育活动结果无关（调整后的模型β=-651.6，t(613)=-1032，p=.303）。
组织层面实施保真度轨迹的差异并未导致患者层面的结果差异。这表明有效的实施保真度轨迹取决于当地组织的条件。更具体地说，实现稳定的高实施保真度需要管理紧张局势：既要实现本地化的变革愿景，又要保护计划的标准化核心组件，并在整个过程中吸引稀缺的医生。在扩大循证健康促进计划时，我们建议根据当地组织的初始位置、规模和情况调整实施紧张局势的管理。
荷兰国家试验注册处 NTR3961。于 2013 年 4 月 18 日注册。
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