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Background Implementing evidence-based interventions (EBIs) in practice requires balancing fidelity and adaptation to suit new contexts. Careful considerations are needed to maintain the core elements for effectiveness while ensuring fit with new contexts. The Adaptation and Fidelity Tool (A-FiT) intervention addresses this challenge by providing support for professionals using EBIs in the sustainment phase of implementation. This study evaluates the A-FiT intervention and examines how professionals delivering an EBI manage fidelity and adaptation during the sustainment phase of implementation, before and after the intervention. Method Short, structured interviews were repeatedly conducted with 14 professionals delivering an EBI (n = 127). Data was analyzed using deductive content analysis focusing on adaptation types, planning, intentionality, and fidelity consistency. The adaptations were counted and compared before versus after the A-FiT intervention using a chi2-test.Results The professionals made about the same number of adaptations before and after the A-FiT intervention. However, after the intervention, significant changes in the type and intentionality of the adaptations were observed. Changes in type consisted of fewer "removing," "substituting," and "integrating another framework" adaptations and more "loosening structure" and "departing from the intervention" adaptations. Regarding intentionality, fewer planned adaptations with the intention of improving the EBI effects were made, while adaptations made for practical reasons, both planned and unplanned, increased after the A-FiT intervention. No statistical change was found regarding fidelity consistency.Conclusions The findings indicate increased awareness about fidelity and adaptation among the group leaders, resulting in fewer planned adaptations to enhance program effects and more practical adaptations to address context challenges. The A-FiT intervention appears to help professionals in their management of fidelity and adaptations when delivering EBIs. The study underscores the importance of understanding adaptations in their context, purpose, and impact (intended and unintended) on the outcome/value.

Evidence-based interventions (EBIs) are effective tools for improving and maintaining health and wellbeing across various settings in society. However, their success relies on balancing adherence to the components and core elements of EBIs that ensure effectiveness with the need to adapt these interventions to fit different contexts. This challenge, known as the fidelity-adaptation dilemma, is highly relevant in practice during the sustainment phase of implementation, where professionals delivering EBIs to target groups are responsible for managing this dilemma. Even though EBIs are a central part of many professionals' working-life, there is limited understanding of how professionals experience the dilemma in practice and how it is associated with their psychosocial working conditions. There is also a gap in knowledge about the sustainment phase, during which professionals are key to the success of EBIs—in other words, they determine to a high degree whether an EBI is effective for its target group through the adaptations they make. Moreover, little is known about how decision support interventions can help professionals balance fidelity and adaptation. The overall aim of this thesis is therefore to explore the fidelity-adaptation dilemma from the professionals' perspective by looking at their perceptions, attitudes, management, and psychosocial working conditions when using EBIs in the sustainment phase of implementation. A secondary aim is to investigate a structured decision support intervention—the Adaptation and Fidelity Tool (A-FiT)— that aims to support professionals in making planned, intentional decisions about fidelity and adaptations.

This thesis comprises four studies, each focusing on different main aspects of professionals' experiences with the fidelity-adaptation dilemma when using EBIs in practice: perceptions (Study I), attitudes (Study II), and psychosocial working conditions (Studies II and IV) but also adaptations made (Study III), and the investigation of a decision support intervention (Studies III and IV). The participants were professionals working with two evidence-based parent education programs in Sweden: Cool Kids (Study I) and All Children in Focus (ABC) (Studies II–IV). The research employed both qualitative and quantitative methods, with cross-sectional and longitudinal designs.

The key findings of the thesis indicate that professionals have varying attitudes toward fidelity and adaptation (Studies I and II) but generally perceive the fidelity-adaptation dilemma as challenging (Study I). Professionals who favored adaptations over fidelity reported more demanding working conditions compared to those who preferred fidelity or valued both equally (Study II). Prompts encouraging reflection on managing fidelity and adaptations were associated with lower perceived skills in delivering the EBI ABC (Study IV). The results also reveal that all professionals made adaptations (Studies I and IV), primarily to better fit the EBI into the context (practical adaptations). While the professionals made about the same number of adaptations both before and after participating in A-FiT, the reasons for making them changed. Practical adaptations increased in number after the professionals participated in A-FiT, while adaptations aimed at improving the EBI's effectiveness decreased (Study III).

This thesis advances the understanding of the fidelity-adaptation dilemma, demonstrating how EBIs can act as both resources and job demands. The findings highlight the importance of reflection both before, during (in), and after (on) action in making effective decisions about fidelity and adaptation, as supported by A-FiT and reflective prompts. Addressing this dilemma requires support beyond the individual level, including education and information about EBIs' components, fidelity, adaptations, and implementation, as well as organizational support and adequate resources, such as opportunities and time to reflect. The thesis emphasizes the need for a balanced approach to fidelity and adaptation for effective EBI sustainment, and calls for further investigation of the dilemma from the professionals' perspective and the impact of tools such as AFiT. Such research, together with the findings from this thesis could contribute to better support for professionals in their management and experience of the dilemma and to that society gains the best possible outcomes from EBIs in the future.

Evidence-based interventions have the potential to improve health and well-being, but their effectiveness depends, among other things, on the challenging act of balancing between fidelity and adaptation, referred to as the fidelity-adaptation dilemma. After initial implementation, it is primarily professionals delivering evidence-based interventions to end users that face the dilemma, but research about how professionals relate to and perceive it is limited. This study aims to describe professionals’ attitudes towards the dilemma and investigate the associations between professional attitudes and individual and organisational implementation determinants, individual characteristics, and work-life consequences for the professionals. Using a cross-sectional design, 103 professionals working with an evidence-based parental support programme ABC (All Children in Focus) were surveyed on attitudes towards the fidelity-adaptation dilemma, implementation determinants, and work-life consequences. Data were analysed using two-step cluster analysis. Three profile groups summarize professionals’ attitudes: one preferring fidelity (the adherers, n = 31), one preferring adaptations (the adapters, n = 50), and one with a dual view on fidelity and adaptation (the double-minded, n = 18). The adherers, the ones preferring fidelity, reported higher levels of skills, knowledge, openness, work-related self-efficacy, meaning of work, and possibilities for development, and a lower level of role conflict and unreasonable tasks compared to the adapters. Professionals with a positive attitude towards fidelity reports experiencing more job resources and a lower level of job demands compared to professionals who are more positive towards adaptation. The study shows that the fidelity-adaptation dilemma is at play during the sustainment phase of implementation and suggest that it has consequences for professionals working life.

Introduction: Adaptations are often necessary to effectively translate evidence-based interventions (EBI) between contexts, but compliance with the EBIs' core components is still important, which is referred to as the fidelity–adaptation dilemma. In the sustainment phase of implementation, it is the professionals delivering the EBIs who are tasked with the decision-making regarding adaptations, but the currently used models and frameworks mostly focus on the initial phases of implementation. To better understand and guide professionals in using EBIs, there is a need to explore professionals' perceptions of the fidelity–adaptation dilemma. The aim of this study is consequently to explore how professionals perceive and navigate the fidelity–adaptation dilemma when using an EBI out of context.

Materials and Methods: Semi-structured interviews were held with 19 psychologists working in primary care. The interviews concerned EBIs in general and Cool Kids, an evidence-based parenting education program designed for children with anxiety that is now used for children with lower levels of anxiety in another setting. The data were analyzed using an inductive content analysis method.

Results: The analysis resulted in two themes: My standpoint regarding fidelity and adaptation is clear and Managing fidelity and adaptations is complicated. The first theme summarizes the professionals' perceptions of confidence for either favoring fidelity or adaptations, as well as reasons for why they made adaptations. For the second theme, the professionals expressed concern about sometimes meeting difficulties with the dilemma when following their original inclination and having second thoughts about the impact the adaptations have in practice.

Conclusion: The professionals generally had strong preferences regarding fidelity and adaptations, but neither preference prevented them from facing difficulties with the dilemma. The results point to a need for better information about possible adaptations from developers but also better support and guidance for professionals when implementing EBIs to ensure quality implementation and facilitate implementation. The results of this study can inform the design of support for professionals in managing the dilemma.

BACKGROUND: Evidence-based interventions (EBIs) can be effective tools for the prevention of disease and health promotion. However, their implementation often requires a delicate balance between the need to adjust the intervention to the context in which it is implemented and the need to keep the core components that make the intervention effective. This so-called dilemma between fidelity and adaptation is often handled by health professionals in the sustainment phase of an implementation (i.e., once the intervention has been adopted and institutionalized in an organization), but not much is known about how and to what extent health professionals are affected by this dilemma. Focusing on the sustainment phase, this project aims to study (1) how fidelity and adaptation are managed by professionals using an EBI, (2) how the fidelity-adaptation dilemma affects professionals' psychosocial working conditions, and (3) how a structured decision support influences professionals' management of the dilemma and their psychosocial working conditions.

METHODS: The study is set in Sweden, and the EBI in focus is a parental program (All Children in Focus). A longitudinal within-person intervention design is used, combined with a cross-sectional survey design. Data sources include web-based questionnaires, brief interviews, fidelity ratings, paper-and-pen questionnaires, and written documentation, collected at multiple time points with both group leaders and parents as respondents.

DISCUSSION: This project approaches fidelity and adaptation from the perspective of the professionals that manage EBIs during the sustainment phase of implementation. Although it is well known that EBIs continue to change over time, it remains to be understood how the fidelity-adaptation dilemma can be managed so that the effectiveness of interventions is retained or improved, not diluted. Moreover, the project adds to the literature by presenting an occupational health perspective on the fidelity-adaptation dilemma. It is acknowledged that fidelity and adaptation may have consequences for not only clients but also the occupational wellbeing of the professionals managing the dilemma, and subsequently, their willingness and ability to deliver EBIs in a sustainable way.