Fidelity and Adaptation: Implementing an Evidence-Based Parenting Program in Community Multicultural Early Learning Centers

Purpose:  This study prospectively examined treatment fidelity and adaptation in implementation of an evidence-based prevention program in community settings. The research was conducted in collaboration with a child mental health center implementing The Incredible Years parenting program (IYPP) through partnerships with early learning centers (ELCs) in a large multicultural North American city. Situating the IYPP in ELCs provided universal nonstigmatizing access and helped to mitigate practical barriers for low-income families. While fidelity is key for evidence-based interventions to make the transition to real-world settings and achieve desired outcomes, new contexts may call for flexible delivery and adaptations. Objectives: (1) examine fidelity  (adherence and competence) in a universal prevention context and under real-world conditions of implementation and supervision, (2) increase understanding of barriers and facilitators and social workers’ adaptations when they depart from the protocol.

Methods: IYPP is a group prevention/early intervention program for high-risk families or those with young children with early onset conduct problems. Consistent with fundamental principles of social work practice, IYPP uses a collaborative approach to empower parents and increase parenting self-efficacy. Treatment content protocol and group process procedures are specified in a comprehensive manual. Eighteen therapists in varying combinations co-led 29 groups at multiple sites serving a range of parents across diverse ethnic groups and socioeconomic levels over 3 years. Mixed methods were used to assess and facilitate understanding of group leaders’ (GLs) adherence to the IYPP protocol. Measures:  Session Leader Checklist, a self-report content adherence checklist that included departures and rationale; Leader Collaborative Process Rating Scale completed during observation of the 4^th and 8^th sessions; ongoing supervisory contact notes and audiotapes of GLs’ regular joint supervisory meetings. A focus group and Evaluation of Program Implementation in Yr3 provided an opportunity for GLs to reflect on their experience conducting multiple groups over an extended time period. We report both degree to which all components were implemented with fidelity throughout intervention and adherence to each component across sessions in the quantitative analysis, and describe strategies for coding and ensuring rigor in qualitative analyses.

Results: Quantitative and qualitative data converged suggesting the IYPP protocol and collaborative group processes were implemented with high fidelity with exceptions of variability in roleplays, video modeling dosage and buddy calls. Fidelity was maintained over time with improvement in ratings for the noted areas in Years 2 & 3. Nine themes emerged around barriers including balancing parent preferences with structured program components, ESL, and challenges implementing IYPP as developed for a high-risk population in a universal preventive setting. Facilitators included emphasis on accountability and ongoing session monitoring, problem-solving barriers and reinforcing adherence in supervision, GLs’ belief in IYPP’s core components and collaborative process, and their sense of ownership and responsibility for implementation.

Implications: Our findings advance knowledge of successful strategies to foster transportability with fidelity of an evidence-based program while maximizing the collaborative process and flexibility of group delivery to respond to the needs of parents from diverse backgrounds. Perceived barriers will be discussed in the context of successful adaptations and strategies that enhanced fidelity.