Implementation refers to “a specific set of activities designed to put into practice an activity or program” (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005, p. 5 ). At first glance, one would assume that a proposed program and the one that is eventually delivered are very similar, that is, that no essential differences appear between the planned program and subsequent practice. However. when practitioners introduce evidence-based programs in new environments, whether in clinics, schools, or community organizations, they rarely—if ever—exactly reproduce the program that was evaluated or that the program developer piloted. They may alter the setting: for example, the Teen Outreach Program (TOP) was initially tested in a school setting, but it is now being replicated in a variety of community-based organizations. Changing the setting from a school, which students are mandated to attend, to a community-based organization, which youth may attend voluntarily may have significant implications for the program’s effectiveness. For a variety of reasons, major changes can occur, so that the new program is not an accurate reproduction of the original version. Strong program implementation requires strength in several dimensions; three important ones are fidelity, adaptation, and dosage.
- Fidelity is the extent to which all the major elements of the original program are faithfully reproduced.
- Adaptation is the extent to which the program is changed or modified.
- Dosage refers to how much of the original program is delivered.
Why is implementation important in all program delivery for all outcomes?
Evidence for the importance of implementation has been obtained in multiple areas including education, mental health, health care, community-based initiatives, technology, industry, and management (Durlak & Dupre, 2008; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005) .
Research clearly indicates that quality implementation is one critical factor associated with program outcomes and is relevant to each aspect of implementation noted above (fidelity, adaptation, and dosage). For example, a review of school-based prevention programs found that implementation quality was the most important program feature associated with outcomes (Wilson, Lipsey, & Derzon, 2003). In some cases, programs have failed to achieve their intended outcomes for youth when implementation was poor whereas, in other cases, program impact was much higher when there were reports of more effective implementation (Durlak & Dupre, 2008). In other words, participants may receive more benefits as a result of better program implementation, or they may receive no significant benefit if program implementation is poor. Some research findings offer additional and dramatic testimony to the importance of implementation. In some situations, it has been possible to compare outcomes when the level of implementation has varied systematically for different subgroups of participants receiving the same intervention. Compared to those receiving lower levels of program implementation , participants in the higher implementation category have demonstrated two or three times as much benefit (DuBois, Holloway, Valentine, & Cooper, 2002; Smith, Schneider, Smith, & Ananidou, 2004). Such data indicate it is clearly worthwhile to strive for more effective implementation.
In sum, implementation is important throughout the entire range and nature of child and youth services, whether the goal is to treat children with adjustment problems, prevent later problems, promote young people’s personal and social development, increase students’ academic performance, promote infant health, or prevent teenage pregnancy. It is possible to think of different points along a continuum as reflecting poor, medium, or high quality implementation and to relate these points to the probability of program success. In general: • Programs are unlikely to achieve any of their goals if they are implemented poorly. • Programs implemented with moderate levels of quality run the risk of failing to achieve their goals or of achieving reduced benefits. • High quality programs are more likely to be successful in achieving and maximizing participant benefits compared with programs of low or moderate quality. Of course, success is never guaranteed, if it were, then we would always know what results would occur in every situation.