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Rural Health Information Hub

Meeting Unique Community Needs

Evidence-based interventions offer communities some assurance their investment of resources will produce results if the program is implemented under the right conditions, with an appropriate audience, and following the right procedures. To get those results, the intervention must be implemented with fidelity.

Fidelity is how closely a program or curriculum mirrors the original design that provided evidence of its effectiveness. Program fidelity can be measured by:

  • Delivery method: Is the program implemented as it was designed?
  • Dosage: How many sessions are held, how long do they last, how often are they held?
  • Setting: Clinic? School? Community?
  • Materials used: Handouts, training materials, videos
  • Target population: Who participated in the program when it was tested?
  • Provider qualifications: What were the qualifications of the providers?
  • Provider training: What kind of training did the people implementing the program receive?

Maintaining Program Effectiveness

Staying true to key elements of a program model is essential to replicate results, with all protocols and guidelines implemented as intended. Program fidelity can be monitored by tracking progress on process objectives, reviewing costs, and monitoring time staff spends on implementation. When adapting a program, these strategies should be used to maintain program effectiveness:

  • Select a program that meets your needs
  • Ensure that staff is committed to program fidelity
  • Contact the program developer
  • Determine key elements that make the program effective
  • Assess the need for cultural adaptation
  • Stay true to the duration and intensity of the original program
  • Avoid program drift
  • Stay up-to-date with program revisions and new materials

You can learn more about each of these steps on the University of Wisconsin Extension Service website.

Adapting Models to be Culturally Appropriate

A common reason for adapting a model is to fit the cultural needs of the target population. Current research suggests that effective programming for participants from multiple cultural backgrounds can be done with proven, culture-generic programs.

It is important to find balance between implementing a program as it was designed and ensuring it is relevant to the target population. Adapting models must be done carefully to avoid removing elements responsible for positive results. Adaptations have been researched to see what changes are and are not acceptable to ensure programs remain effective. These changes can be made on a surface level or deep level.

  • Surface level adaptations
    Tailoring of language, visuals, examples, scenarios, and activities used during the intervention. These adaptations generally will not reduce program effectiveness.
  • Deep level adaptations
    Altering program structure and goals, which have a potential to reduce program effectiveness. The need for deep level adaptations may also mean the program does not match the intended audience and other programs may be a better fit.
  • Acceptable changes
    Making these changes will not alter the theory and internal logic of the intervention and ensure critical steps contributing to the intervention effectiveness are maintained. They include:
    • Translating language or modifying vocabulary
    • Replacing cultural references
    • Modifying some aspects of activities
    • Adding relevant evidence-based content to make the program more appealing
  • Unacceptable changes
    These changes make a substantial change to a program’s potential effectiveness:
    • Reducing number or length of program sessions
    • Lowering participant engagement
    • Eliminating key messages or skills learned
    • Removing topics
    • Using inadequately trained staff
    • Using fewer staff members than recommended.

The Society for Public Health Education (SOPHE) has also highlighted elements of interventions that can and cannot be modified when dealing with program fidelity:

  • Aspects that can be modified
    • Names
    • Pictures/testimonials
    • Wording
    • Location
    • Incentives
    • Timeline
  • Aspects that cannot be modified
    • Health topic
    • Deletion of key components
    • Insertion of key components
    • Theoretical foundation (e.g. behavior change theory)

For more information on modifications to interventions, please see
The Cultural Adaptation of Prevention Interventions: Resolving Tensions between Fidelity and Fit, Castro, F.G., Barrera, M., & Martinez, C.; Prevention Science, 5(1), 41-45, March 2004.