A Focus on “Fidelity” – When is poor adherence actually helpful adaptation?
January 21, 2020 | Eric Bruns
There is a phrase I often hear from the many implementation scientists I work with at the University of Washington School Mental Health Assessment, Research, and Training (SMART) Center. That phrase is: “there is no implementation without adaptation.” That is to say, when we take a research-based strategy into the real world, education leaders and school staff who are using it will always adapt it in some way to try to make it fit their own context and reality. Not only is this inevitable, it is often necessary to ensure success.
My colleague, Claire Crooks from Western University in Ontario, Canada, recently spoke of this phenomenon as it pertained to her own intervention, The 4th R. As she was presenting, I realized this trajectory could also easily be applied to Wraparound. Dr. Crooks describes the “fidelity trajectory” she has observed over the lifespan of interventions as follows:
Phase 1: The fidelity problem – A good idea (like Wraparound) is innovated and shows promise… but the field ignores fidelity guidelines or implementation parameters (or maybe they have not yet been developed). Poor implementation becomes the norm, outcomes fail to be replicated, and the field is ready to discard the once promising idea.
Phase 2: The fidelity “solution” – To overcome “poor implementation” of the good idea, fidelity standards arise, and the field imposes rigid and doctrinaire implementation standards. This helps some programs achieve better outcomes, but other systems and organizations are left out, either due to high costs of implementation or a lack of “fit” between the strict standards and what they can achieve in their own systems. At the same time, the field learns ways to do the practice better that are not accommodated in the existing fidelity framework. People worry that the existing fidelity is outdated. Others worry about how to innovate and adapt given that the growing evidence base is based on the old fidelity framework.
Phase 3: Facilitate adaptation and model flexible implementation – community programs and researchers work together to determine how best to identify and retain the most critical elements of the program or strategy, while allowing changes to enhance fit to the system, organization, population of focus, or other element. Ideally, this helps assure the uptake of the program into more and more settings, without major compromises to the outcomes.
The Centers for Disease Control have described a heuristic for the “Facilitate adaptation” phase of a research-based program or strategy’s developmental lifespan, called the Traffic light framework:
- RED: Unhelpful changes that remove critical elements that, for example, build skills needed for success in the client(s) being served
YELLOW: Changes that can be made with caution – perhaps to a program where the essential elements have not been identified
- GREEN: Changes that enhance fit to the local context, but that retain the “essential elements” needed to achieve outcomes.
The above observations, and the “traffic light” analogy is no different in Wraparound than for school mental health strategies. The question is: What are the core elements? The National Wraparound Implementation Center (NWIC) focuses its training and coaching on four “essential elements” of Wraparound:
- Effective Teamwork,
- Strength- and Family-driven,
- Needs-based, and
Reflecting on this theme, John VanDenBerg observed in his 2016 National Wraparound Implementation Academy keynote that we probably already have some ideas on what is necessary to do “minimalist Wraparound”:
- Rapid engagement and crisis response
- Basing Wraparound plans on a small number of priority needs, described in the family’s voice
- Building social support
- Skill building for youths, caregivers, and family members
- Monitoring and feedback of the plan and its strategies, family perspectives, and outcomes
Of course, just because we identify a smaller number of critical elements doesn’t mean they are easy to do. Rapid engagement requires low caseloads and flexible programs. Developing needs statements as per approaches promoted by NWIC requires skilled staff and flexible funding to “do whatever it takes” to meet those needs. Building social support for some families takes lots of effort and may require help from trained parent and youth peer partners. Skill building (e.g., for youth to manage stress or for parents to manage behavior) often requires availability of evidence-based treatments. And monitoring and feedback is facilitated by good data systems and supervision.
As Wraparound continues to evolve and mature, we should be careful to not be too doctrinaire about fidelity, and instead allow adaptation in local implementation efforts. We should also continue to do research on which practice and program elements are associated with the most consistently positive outcomes. The University of Washington Wraparound Evaluation and Research Team is currently working on a research protocol to do just that.
In the end, identifying core elements and facilitating helpful adaptation will aid our collective effort to make high-quality Wraparound available to as many youth and families in need as possible.