it technology strategy tactics and operations fidelity pdf

It Technology Strategy Tactics And Operations Fidelity Pdf

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Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. Implementation is sometimes compared to an engineering process because it requires a combination of methods and tools that are based in research but intended to guide a complex, real-world activity with many moving parts.

Effectively implementing a program on a broad scale is a process that takes time and requires ongoing evaluation and adaptation to local circumstances Aarons, Hurlburt, and Horwitz, ; Metz and Bartley, ; Meyers, Durlak, and Wandersman, There are several prerequisites to effective implementation. The program needs to be based on a sound theoretical model that characterizes precisely how it can be expected to bring about a desired change.

During the past decade, implementation research has focused both on the foundations that support the process—the development of a design that highlights essential components needed for effectiveness while allowing for adaptation to suit diverse populations—and the process itself—what it takes to deliver an intervention at a scale that can benefit broad populations. Thus, the term scale-up refers to systematic ways of increasing the coverage, range, and sustainability of the intervention, such as by taking a tested, effective local program to the regional, national, or international level Ilott et al.

This chapter focuses on three elements of sound program design that support effective implementation:. Hendricks Brown, personal communication. Effective implementation of an intervention starts with identifying its core components and the logic model or theory of how those components are intended to bring about the desired outcome. Also sometimes referred to as the active ingredients, essential elements, or mechanisms of change, core components are those variables that are essential if a program is to function as designed.

Examples include the development of particular skills, such as self-management, decision making, drug resistance, or coping with stress and anxiety Botvin and Griffin, Identifying those components that are truly essential makes it possible to then adapt nonessential elements to meet local needs and preferences Fixsen et al. This process is supported by mediation research, which entails searching for mediating factors—those that explain how the core components actually operate—as well as other factors such as sex, class, or race that moderate those relationships.

Mediation studies can also support dissemination by suggesting how interventions might be made more efficient without sacrificing impact. The sections below describe this process in greater detail. Researchers studying mediating factors in family- and school-based interventions have explored a variety of child and adolescent intervention outcomes, including effects on child conduct problems and externalizing behaviors, school engagement and achievement, depression and anxiety symptoms, initiation of and growth in substance use, and delinquency and arrests Carreras et al.

Studies typically examine the role of one or two of many possible mediating mechanisms by which an intervention is thought to work. For example, Sandler and colleagues examined the mechanisms through which parenting interventions affect child outcomes.

Their work suggests that long-term intervention effects are best understood in the context of changes in social, cognitive, behavioral, and biological processes in parents and their children, as well as transactions between youth and their social contexts. Other researchers have used longitudinal studies to examine mediating factors, capitalizing on research designs that can potentially support causal statements by collecting data in three or more waves—examining direct intervention effects first, then targeting mediating constructs, and then measuring longer-term outcomes Fairchild and MacKinnon, ; Gonzales et al.

Several examples illustrate the types of mediators being examined in intervention studies; research of this kind provides clues to the potential core components of interventions. Perrino and colleagues integrated data from three trials of the family intervention program Familias Unidas to examine mechanisms by which the.

Familias Unidas is a community counseling and information center serving primarily Hispanic families that focuses on increasing positive parenting, family support, and parental involvement and improving parent—adolescent communication.

Results of previous tests have found modest to large effect sizes depending on the outcome and trial Prado and Pantin, The researchers focused on the mediating role of one proximal intervention target—parent—adolescent communication—and three moderators—baseline levels of internalizing symptoms, externalizing symptoms, and parent—adolescent communication.

They found that the communication component fully mediated intervention effects on levels of internalizing symptoms, particularly among families with lower levels of parent—adolescent communication skills at baseline, providing support for the hypothesis that parent—adolescent communication is an effective component of the Familias Unidas intervention curriculum. DeGarmo and colleagues sought to test mediators in their study of a universal school-based intervention for early adolescents—Linking the Interests of Families and Teachers LIFT —aimed at preventing antisocial behavior, including youth substance use.

The intervention focused on proximal intervention targets—strengthening positive relationships between young people and their parents and peers—because of evidence that these relationships have a protective effect with respect to antisocial behavior and early substance use. Intervention components included parent training, training for children in social and problem-solving skills, a recess intervention game the Good Behavior Game 3 , and encouraging communication between parents and teachers.

The researchers hoped to understand the possible mediating effects of family problem solving and reduction in peer playground aggression on long-term outcomes for the LIFT intervention with respect to initiation and growth of substance use through grade They found that intervention-related effects on reducing average tobacco use were mediated by improvements in family problem solving, while effects on growth in substance use were mediated by family problem solving and reductions in playground aggression.

This work highlights that mechanisms and associated program components may play different roles for different outcomes: family training in problem-solving skills and the Good. See also Box in Chapter 4. Behavior Game may be critical components for substance use, but family problem solving alone may be sufficient for tobacco use.

Communities That Care CTC is a strategy developed by researchers at the University of Washington for providing workshops, instructional materials, and other resources to communities and states over the Internet. Brown and colleagues assessed the influence of five possible community-level mediators of the effects of CTC on youth substance use and antisocial behavior.

Another study examined community adoption of the program by surveying community members about their awareness and use of prevention science concepts, use of epidemiological data, and system monitoring Cambron et al. The studies of mediation described above show how the operation of core theoretical constructs can be established and how specific components of an intervention influence long-term outcomes. However, such studies do not provide strong evidence about which components of interventions can be dropped to make the program more efficient.

With CTC, for example, the benefits likely occur not solely as a result of half-day orientation sessions for leaders; rather, the training of a well-functioning community coalition to use tools and decision-making processes in selecting evidence-based programs and implementing them with fidelity is likely extremely important. Methods for isolating the core components of an intervention more precisely have been proposed.

Dismantling or factorial designs methods for disentangling potentially influential factors could provide robust evidence about which intervention components are necessary to produce desired effects on youth. One such approach, the Multiphase Optimization Strategy, uses a three-step process based on engineering principles Collins and Kugler, ; Collins et al.

In the first step, a variety of experimental methods are used to assess an array of interventions or delivery components; a second set of experiments is used to confirm the identification of essential components; and finally, efficacy and effectiveness are confirmed in randomized controlled trials.

Other work has also used trials of a range of intervention components to identify those that are essential, beginning with a thorough evaluation of a single multicomponent intervention Collins, ; Collins, Murphy, and Strecher, ; Danaher and Seeley, ; Lindquist et al. Mediating constructs, such as community adoption of particular prevention strategies, may be complex, so disentangling them into more discrete elements may further illuminate causal mechanisms.

Moreover, because many preventive interventions are intended to influence multiple outcomes, potentially through multiple proximal intervention targets, holistic analyses are often desirable. Once core components of a program have been established, monitoring the fidelity with which they are being implemented as the program is being designed and tested is critical.

Yet systematic attention to both fidelity monitoring and the role of core components has been neglected in the past and still is Dane and Schneider, ; Jensen et al. While fidelity monitoring is important in efficacy trials, moreover, it becomes even more so—and more complicated—once an intervention has been put into practice in real-world environments Crosse et al.

Although the value of consistent quality monitoring has long been recognized, securing the necessary resources and managing the increased burden such monitoring can place on service systems, practitioners, and consumers can be significant challenges Aarons, Fettes, et al.

Regardless, without data to suggest whether a program has been implemented with fidelity, it is unclear whether program outcomes can accurately be attributed to the program itself or whether poor implementation was a culprit in unexpected outcomes Fixsen et al. Researchers have suggested ways to support fidelity assessment in both the research and scale-up stages of an intervention refer to Box Increasing the connections among clearly identified core intervention components, fidelity assessments, and intended intervention outcomes, as well as ensuring much more rigorous monitoring of core intervention components in both research and.

These recommendations also make clear that fidelity monitoring is a shared responsibility for implementing organizations or evaluators, supported and reinforced by stakeholders. Although identifying the core components of a program is critical, a growing body of research is emphasizing that programs are more effective and sustainable if they are responsive to local needs, preferences, and capacities Horner, Blitz, and Ross, ; Walker, Bumbarger, and Phillippi, The diversity of the U.

Adapting programs to suit the local context requires care, however. However, they also describe the tension between making adaptations and preserving the elements essential for effectiveness, and note the limited research on cultural, racial, and ethnic issues related to adaptation of interventions. Over the past two decades, researchers have developed several frameworks for cultural adaptation.

For example, the Ecological Validity Model describes eight dimensions to be considered: language, persons, metaphors, content, concepts, goals, methods, and context Bernal, Bonilla, and Bellido, , and ADAPT-ITT provides a process framework for steps in adaptation, such as assessment to understand the target population, pretesting, consultation with topical experts, and pilot testing Wingood and DiClemente, Despite this thinking about what is important in adapting programs to meet the needs of diverse communities, a recent meta-analysis of studies of the effects of cultural adaptations on treatment outcomes suggests that results thus far have been mixed Gonzales, A prior meta-analysis of ethnic minority children and adolescents who had received an evidence-based intervention showed no difference in outcomes for culturally adapted and nonadapted interventions Huey and Polo, , while other meta-analyses combining child and adult studies have found that culturally adapted interventions had modestly better effects,.

For example, in a survey of Pennsylvania program grantees, 44 percent of respondents reported making adaptations to program procedures, dosage, and content, both intentional and not Moore, Bumbarger, and Cooper, Reasons cited were primarily logistical in nature: lack of time, limited resources, and difficulty with participant engagement. In their systematic review of four widely disseminated evidence-based parent training interventions, Baumann and colleagues found only 8 of published studies that met their strict criteria for cultural adaptation; they advocate documenting explicitly how, why, and for whom adaptations were made see, e.

These mixed findings suggest that, although surface adaptations may be necessary to ensure that interventions are culturally sensitive to and engage the populations being served, more rigorous research is needed to determine whether deep adaptations are warranted.

Some researchers have noted the time and cost of evaluating these adaptations and the resulting potential delay in dissemination of effective treatments to those most in need Domenech Rodriguez, Baumann, and Schwartz, Further, it may be best if intervention developers examine broad issues of culture and context in the development process, while gathering input from multiple constituencies.

Research on how to adapt programs effectively to serve diverse populations increasingly highlights the importance of engaging directly with communities.

For MEB interventions, one way to accomplish such engagement and to respond directly to community needs is to engage community health workers in delivering the interventions. Such workers are often from the same community as the clients being served, and evidence of the effectiveness of this approach has been found in a variety of settings and for a variety of targeted problems in research conducted both in the United States and in other countries Barnett et al.

This research has addressed topics ranging from the delivery of a parenting intervention to Native American families to treatment for traumatic stress and mental disorders Barlow et al. However, such barriers as rules and policies related to reimbursement e. Looking more broadly, multiple studies have shown community partnership and consultation in adaptation and implementation to be an effective approach Barrera, Castro, and Steiker, ; Baumann et al.

An example of this approach is community-based participatory research CBPR , which emphasizes reciprocal knowledge exchange and mutual benefit among partners Minkler and Wallerstein, ; Wallerstein and Duran, A recent meta-analysis of eight programs using this approach found improvements in both health outcomes for individuals and.

Another study, in the context of targeting depression, compared the results for a CBPR-based approach with those for standard strategies for delivering depression care. The authors found that the results for some indicators were equivalent but others were better with the CPBR-based approach Wells et al.

Positive results have been documented for the CBPR approach in child and youth mental health interventions as well Betancourt et al. Native American youth have long been at particularly high risk for dropping out of high school, substance use disorders, teen pregnancy, and suicide. These high risks have been attributed to multiple factors, including poverty, historical and acute trauma, and lack of access to evidence-based prevention interventions Brockie et al. Studies using a CBPR approach to promote mental health among Native American youth have also demonstrated positive effects Goodkind et al.

A study of two interventions for prevention of alcohol abuse among youth in a rural Native American community that were adapted for the local culture—Communities Mobilizing for Change on Alcohol CMCA , a community organizing intervention, and CONNECT, a school-based universal screening and brief intervention—showed that both effectively decreased individual-level alcohol use and heavy episodic drinking Komro et al. The CMCA intervention also had community effects on reducing overall access to alcohol among underage youth Komro et al.

An alternative to adapting an existing evidence-based intervention is when local practitioners develop interventions based on the real-world needs and cultures of specific communities Marsiglia and Kulis, This approach, often referred to as the use of practice-based evidence, highlights culturally specific interventions and healing practices that are used in ethnic minority communities and reflect the beliefs and values of the local community Isaacs et al.

Initiatives developed in this way may be well accepted as effective by the local community. However, one recent examination of interventions in use in a statewide setting showed that few practices, regardless of whether they were based on research or practice-based evidence, were culturally specific Lyon et al. Moreover, most of the cultural features noted reflected only surface-level program characteristics, such as providing services in languages other than English or provider—recipient matching, rather than deep content characteristics that attend to cultural values and other central cultural components Lyon et al.

Implementation strategies are methods and tools used to change policies, administrative procedures, and environments; they are the how of implementation, the means through which core components are put into practice. Such strategies might include, for example, engaging program consumers, providing training and technical support to staff delivering the program, or garnering stakeholder support for the program.

The evolution of implementation science has included a focus on identifying, classifying, and studying these basic elements of the implementation process Proctor, Powell, and McMillen, This section reviews in turn discrete and blended implementation strategies, providing three examples of the latter, and then examines the evidence on ways of supporting implementation efforts. Some implementation strategies are discrete—single actions or processes e. Researchers have examined discrete strategies and identified an array of purposes they serve, including engaging consumers of the program being implemented, developing relationships with other stakeholders, supporting practitioners, and providing interactive assistance or training Powell et al.

Such actions are the building blocks of more complex strategies, and researchers have analyzed them in seeking to identify core implementation components and track and assess fidelity.

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Companies have only three options: attack, coexist uneasily, or become low-cost players themselves. None of them is easy, but the right framework can help you learn which strategy is most likely to work. Companies find it challenging and yet strangely reassuring to take on opponents whose strategies, strengths, and weaknesses resemble their own. Their obsession with familiar rivals, however, has blinded them to threats from disruptive, low-cost competitors. Successful price warriors, such as the German retailer Aldi, are changing the nature of competition by employing several tactics: focusing on just one or a few consumer segments, delivering the basic product or providing one benefit better than rivals do, and backing low prices with superefficient operations.


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