Can Systematic Implementation Support Improve Program Fidelity by Improving Care Providers’ Perceptions of Implementation Factors? A Cluster Randomized Trial

Abstract

Background: Investigations of implementation factors are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcome, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by program fidelity) and care providers’ perceptions of implementation factors during an implementation process and to investigate whether these perceptions can be 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. Program fidelity and care providers’ perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups every sixth month for 18 months. Assessments 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 program 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 high fidelity of recommended practices. Trial registration: ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).