School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden.
Medical Management Centre, LIME, Karolinska Institutet, 171 77, Stockholm, Sweden.
BMC Health Serv Res. 2019 Nov 21;19(1):868. doi: 10.1186/s12913-019-4668-y.
There has long been debate about the balance between fidelity to evidence-based interventions (EBIs) and the need for adaptation for specific contexts or particular patients. The debate is relevant to virtually all clinical areas. This paper synthesises arguments from both fidelity and adaptation perspectives to provide a comprehensive understanding of the challenges involved, and proposes a theoretical and practical approach for how fidelity and adaptation can optimally be managed.
There are convincing arguments in support of both fidelity and adaptations, representing the perspectives of intervention developers and internal validity on the one hand and users and external validity on the other. Instead of characterizing fidelity and adaptation as mutually exclusive, we propose that they may better be conceptualized as complimentary, representing two synergistic perspectives that can increase the relevance of research, and provide a practical way to approach the goal of optimizing patient outcomes. The theoretical approach proposed, the "Value Equation," provides a method for reconciling the fidelity and adaptation debate by putting it in relation to the value (V) that is produced. The equation involves three terms: intervention (IN), context (C), and implementation strategies (IS). Fidelity and adaptation determine how these terms are balanced and, in turn, the end product - the value it produces for patients, providers, organizations, and systems. The Value Equation summarizes three central propositions: 1) The end product of implementation efforts should emphasize overall value rather than only the intervention effects, 2) implementation strategies can be construed as a method to create fit between EBIs and context, and 3) transparency is vital; not only for the intervention but for all of the four terms of the equation. There are merits to arguments for both fidelity and adaptation. We propose a theoretical approach, a Value Equation, to reconciling the fidelity and adaptation debate. Although there are complexities in the equation and the propositions, we suggest that the Value Equation be used in developing and testing hypotheses that can help implementation science move toward a more granular understanding of the roles of fidelity and adaptation in the implementation process, and ultimately sustainability of practices that provide value to stakeholders.
长期以来，关于证据基础干预措施（EBIs）的忠实度与适应特定背景或特定患者的需求之间的平衡一直存在争议。这场辩论与几乎所有临床领域都息息相关。本文综合了忠实度和适应度的观点，为理解所涉及的挑战提供了全面的认识，并提出了一种理论和实践方法，以最佳地管理忠实度和适应度。
有令人信服的论据支持忠实度和适应度，一方面代表了干预措施开发者和内部有效性的观点，另一方面代表了用户和外部有效性的观点。我们不将忠实度和适应度描述为相互排斥的，而是建议它们可以更好地被概念化为互补的，代表了两种协同的观点，这可以提高研究的相关性，并为实现优化患者结果的目标提供一种实用的方法。所提出的理论方法，即“价值方程”，通过将其与产生的价值（V）联系起来，为调和忠实度和适应度的争论提供了一种方法。该方程涉及三个术语：干预（IN）、背景（C）和实施策略（IS）。忠实度和适应度决定了这些术语的平衡方式，进而决定了最终产品——为患者、提供者、组织和系统产生的价值。价值方程总结了三个核心命题：1）实施工作的最终产品应强调整体价值，而不仅仅是干预效果；2）实施策略可以被视为在 EBI 和背景之间创造契合的一种方法；3）透明度至关重要；不仅对干预措施，而且对方程的所有四个术语都至关重要。忠实度和适应度的观点都有其优点。我们提出了一种理论方法，即价值方程，以调和忠实度和适应度的争论。尽管方程和命题存在复杂性，但我们建议在制定和测试假设时使用价值方程，这有助于实施科学更深入地理解忠实度和适应度在实施过程中的作用，并最终使为利益相关者提供价值的实践得以持续。
