To adapt or not to adapt: the association between implementation fidelity and the effectiveness of diabetes self management education

Abstract

Self-management education (SME) is a key determinant of diabetes treatment out-20 comes. While SME programs are often adapted for implementation, the impact of adapta-21 tions on diabetes SME effectiveness is not well documented. This study evaluated the impact 22 of the implementation fidelity of diabetes SME programs on program effectiveness, explor-23 ing which factors influence implementation fidelity. Data from 33 Type-2 diabetes SME pro-24 gram providers and 166 patients were collected in 8 countries (Austria, Belgium, Germany, 25 Ireland, UK, Israel, Taiwan and USA). Program providers completed a questionnaire as-26 sessing their adherence to the program protocol and factors that influenced the implementa-27 tion. Patients answered a pre-post questionnaire assessing their diabetes- related health lit-28 eracy, self-care behavior, general health and well-being. Associations between implementa-29 tion fidelity and outcomes were estimated through logistic regressions and repeated-30 measures MANOVA, controlling for potential confounders. Adaptations of the program pro-31 tocol regarding content, duration, frequency and/or coverage were reported by 39% of the 32 providers, and were associated with better, not worse, outcomes than strict adherence. None 33 of the factors related to the participants, facilitating strategies, provider or context systemat-34 ically influenced the implementation fidelity. Future research should focus on individual and 35 contextual factors that may influence decisions to adapt SME programs for diabetes.

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ORCID for Lucy Yardley: orcid.org/0000-0002-3853-883X

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