STEP 4: Implementation

Step 4

In this phase of the SPF process, your role shifts from planning to oversight, mutual accountability, and monitoring of the implementation process. During implementation, you carry out the various components of your action plan and address any barriers that arise.

STEP 4: Implementation comprises the following primary tasks:

TASK 1: Assess Capacity for Implementation

Assess your group’s capacity to implement the selected strategies by answering three questions:

  • What capacity is required to implement these strategies?
  • Does your group have that capacity?
  • If not, how will you improve your capacity?

Partners who are involved in the assessment and planning processes may find that they lack the skills needed to carry out one or more of the selected strategies. A plan to improve capacity may include involving additional community partners who already have appropriately trained staff, hiring staff with the necessary expertise, or providing training opportunities for staff and members who will be involved in implementing the intervention.

Everyone involved in the effort should understand his or her role in implementing the identified strategies. Ensure that all partners understand the group’s goals and selected strategies, the specific contributions of each partner, and how the activities to be implemented will lead to the desired outcomes.

Avoid having the tasks of implementation simply given to staff members, while others sit back and expect to hear about how the work is going without being directly involved. Staff may be able to fill a number of important roles, including preparing meeting minutes, compiling reports, coordinating meetings, facilitating communication with partners, maintaining accurate records for funding and reporting requirements, and assisting with planning, problem solving, and information management. However, with all these roles to fill, staff cannot also be expected to implement all the selected strategies by themselves.

Suggestions for sharing the work of implementation:

  • Form small committees that each focus on a specific strategy
  • Ask some members to be program “champions,” who speak about and promote the strategies in the community
  • See if any members have connections to organizations or other professional and personal spheres of influence that they can leverage as resources for change in the community (e.g., use their connections to help implement an inter-organizational prevention effort)
TASK 2: Ensure Fidelity

Fidelity is the degree to which an intervention is implemented as its original developer intended. Interventions that are implemented with fidelity are more likely to replicate the results from the original intervention than are those that make substantial adaptations. Training on how to implement the intervention, especially if it’s available from the program developer, will increase your ability to implement with fidelity.

That being said, at times it may be necessary to adapt the intervention to better fit your local circumstances or meet your needs. For example

  • Your target population may be different in some way from the population that was originally evaluated
  • Some intervention elements may need to be adjusted due to budget, time, or staffing restraints

Balancing fidelity and adaptation can be tricky, since any time you change a strategy or intervention, you may compromise the outcomes. Even so, implementing an intervention that requires some adaptation may be more efficient, effective, and cost-effective than designing a new one.

Some general guidelines for adapting an intervention:

  • Select strategies with the best initial fit to your local needs and conditions. This will reduce the likelihood that you’ll need to make adaptations later.
  • Select strategies with the largest effect size—the magnitude of a strategy’s impact. For example, policy change generally has a larger effect size than a classroom-based program. The smaller a strategy’s effect size, the more careful you need to be about changing anything, since you don’t want to inadvertently compromise any good that you are doing. In general, adaptations to strategies with large effect sizes are less likely to affect relevant outcomes.
  • Implement the strategy as written before making adaptations, since you may find that it works well without having to make changes.
  • When implementing an evidence-based intervention, consult with the intervention developer before making adaptations. The developer may be able to tell you how the program has been adapted in the past and how well these adaptations have worked. If the developer is not available, work with an implementation science expert or your evaluator.
  • Retain the core components, since there is a greater likelihood of effectiveness when an intervention includes these components. If you aren’t sure which elements are core, refer to the intervention’s logic model, if it is available, or consult the program developer or your evaluator for assistance.
  • Stick to evidence-based principles. Strategies that adhere to these principles are more likely to be effective, so it is important that adaptations are consistent with the science.
  • Adjust your coalition’s capacity before you adapt an intervention. While it may be easier to change the intervention, changing local capacity to deliver it as it was designed is a safer choice.
TASK 3: Consider Cultural Adaptation

Providing culturally competent programming, activities, and interventions begins with a clear and comprehensive understanding of your community. With this foundation, you can put together a full menu of appropriate programs, interventions, and activities that meet your community members where they are, with service providers who understand their needs and are able to fulfill them.

Cultural adaptation refers to program changes that are culturally sensitive and tailored to a particular group’s traditional world views. Effective cultural adaptation is especially important when it comes to implementation.

Too often, people equate cultural adaptation with translation, but it is much more than that. Effective cultural adaptation considers the values, attitudes, beliefs, and experiences of the target audience. It depends on strong linkages to cultural leaders and access to culturally competent staff.

Making sure that your intervention is simply available to the target audience is not sufficient. Integrating the principles of cultural competence into the implementation phase will help ensure that your intervention is accessible to and effective with the identified target population. This requires paying attention to logistical issues, for example:

  • Transportation
  • Flexible operating hours
  • A sliding fee schedule
  • Offering services in a variety of languages, with translation and interpreter services.

Depending on their cultural, historical, or ethnic background, some parents may be resistant to take part in your group’s programs and services. Explaining the nature and benefits of services to parents in terms that are acceptable, understandable, and amenable to them can help overcome this resistance.

Consider cultural competence when seeking community partners and service providers as well. Enlist clinicians and other providers who have the capacity to provide culturally and linguistically competent services. You might also develop a policy statement that any services provided will be uniformly culturally and linguistically competent and of high quality. Ensuring diversity among your partners and in your leadership and developing links with community institutions are all good strategies for supporting cultural competence.32

TASK 4: Monitor Implementation of Plan

In addition to carrying out the activities in your implementation plan, your group needs to document the implementation process and describe any changes you make to your original plan along the way. This provides information on the fidelity of the implementation and will be part of your process evaluation. Information to document may include participant demographics, recruitment methods, actual attendance, planned and implemented adaptations, cultural issues and how they were addressed, indications of unmet needs, and any other issues that arise (e.g., lack of organizational capacity, community resistance).

Generally, within three to six months of beginning a new strategy or activity, your staff or an appropriate committee should develop a systematic way to review your logic model and strategic plan and do the following:

  • Document intervention components that work well
  • Identify where improvements need to be made
  • Provide feedback so that strategies may be implemented more effectively
  • Make timely adjustments in activities and strategies to better address identified problems
  • Assess whether enough resources have been leveraged and where you might find more
  • Engage key stakeholders so they feel a sense of responsibility and pride in helping to ensure that the goals and objectives of the coalition are met and that the opioid misuse problem in the community is reduced

One way to review your logic model and strategic plan is to create a fidelity checklist, if one is not already available from the intervention developers. First, list all the activities in your action plan and put a check box next to each activity. Next, check off each activity as you complete it and document the following:

  • Activities that were not implemented in the order suggested by developers
  • Activities you tried that did not work
  • New activities you created to take the place of ones that did not work

At the end of this process, you will have a good record of what you did and did not implement, the challenges you faced, and how you overcame each challenge.

TASK 5: Plan for Sustainability

The implementation of strategies to bring about significant community change rarely takes place in a short time frame. As you build capacity to bring about change, be aware of the need to generate resources to sustain your strategies, beyond simply the expense of carrying out an intervention. To do this, it is important to invest in capacity, teach people how to assess needs, build resources, and effectively plan and implement prevention interventions to create the systems necessary to support these activities going forward.

Sustaining your work includes both institutionalizing strategies and finding additional financial support for them―both of which should be planned for by the time you begin to implement activities.

Institutionalizing Your Work

This is a long-term process—it may take years to build a comprehensive solution.

One key strategy is to form a working group of staff and coalition partners to focus on sustainability planning:

  • Finding ways to make the policies, practices, and procedures you have established become successfully rooted in the community
  • Considering the existing systems and frameworks relevant to your work, which can be stepping stones to eventual policy changes
  • Looking for ways to integrate your work into existing departments within a municipality or into other organizations

Getting key stakeholders involved from the beginning and providing leadership opportunities can inspire them to become champions who will fight to sustain your activities; the more invested your partners become, the more likely they will be to support your group’s activities in the long term.

Finding Additional Resources

Planning for financial stability involves figuring out strategies and action steps for your group to obtain and grow the diverse resources—human, financial, material, and technological—needed to sustain your efforts over time. Additional resources may include in-kind support, volunteer staff, commitments for shared resources from other organizations, or another organization who might take on a project begun by your group.

More on sustainability is available here.