STEP 4: Implementation

In Step 4, you will focus on carrying out the various components of your action plan, and identifying and overcoming any potential barriers. You will assess your capacity to carry out the implementation plan, determine what training or other assistance is needed, and decide how to engage additional community partners who have the necessary expertise.

The role of your group now shifts from planning to oversight, mutual accountability, and monitoring of the implementation process. You must make sure that the plan is implemented with fidelity, allowing for adaptations only when necessary. It is especially important to integrate the principles of cultural competence into the implementation phase, so that the intervention is accessible to and effective with the identified target population.

At this point, it is important to make sure that all partners agree with and understand the identified goals and selected strategies, their own specific contributions, and how the activities to be implemented will lead to the desired outcomes.

STEP 4: Implementation comprises the following primary tasks:

TASK 1: Assess and Build Capacity for the Implementation Phase

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 (e.g., organization, coalition, cluster) have that capacity?
  • If not, how will you improve your capacity?

These questions should be addressed in your strategic plan.

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. When seeking community partners, keep in mind the principles of cultural competence; ensuring diversity among your partners and developing links with community institutions are good strategies for supporting cultural competence.36

Everyone involved in the effort should understand his or her role in implementing the identified strategies. All too often, the tasks of implementation are handed over to a few 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 the selected strategies by themselves.

You may consider forming small committees that will each focus on a specific strategy. In doing so, remember to support cultural competence by ensuring diversity in your leadership. Providing additional leadership opportunities can also be an integral way to promote sustainability. The more invested your partners become, the more likely they will be to support your group’s activities in the long term.

Some members may be willing to become program champions—those who speak about and promote the strategies in the community. In addition, members can leverage resources for change in the community through their professional and personal spheres of influence. For example, a member might serve as a liaison to help implement an inter-organizational prevention effort, bringing together organizations to which he or she has connections.

TASK 2: Address Fidelity and Adaptation

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 implementation of the 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.

However, although ensuring fidelity is an important concern, at times adaptation may be necessary tobetter fit your local circumstances. You may find, for example, that you are working with a target population that is in some way different from the population that was originally evaluated, or that some intervention elements must be adjusted due to budget, time, or staffing restraints. In these cases, it may be necessary to adapt the intervention to meet your needs. Balancing fidelity and adaptation can be tricky—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 intervention.

Here are 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 will need to make adaptations later.
  • Select strategies with the largest possible effect size—the magnitude of a strategy’s impact. For example, policy change generally has a larger effect size than classroom-based programs.

Note: The smaller a strategy’s effect size, the more careful you need to be about changing anything. 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, if possible, before making adaptations, since you may find that it works well without having to make changes.
  • When implementing evidence-based interventions, consult with the intervention developer when possible 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 interventions that include these components have a greater likelihood of effectiveness. 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.
  • Change your coalition’s capacity before you adapt an intervention. While it may seem easier to change the intervention, changing local capacity to deliver it as it was designed is a safer choice.

Cultural adaptation refers to program changes that are culturally sensitive and tailored to a particular group’s traditional worldviews. 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.

TASK 3: Monitor the Implementation Plan

In addition to carrying out the activities in your implementation plan, your group will need to document the process and describe any changes you make to your original plan along the way. A complete description of how your intervention was implemented helps provide information on fidelity of the implementation; this is part of the process evaluation described in Step 5 of the SPF. 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. The goals of this review are as follows:

  • 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 (e.g., community members, providers, staff) so they feel a sense of responsibility and pride in helping to ensure that your group’s goals and objectives are met and that the substance use problem in the community is reduced

One way to do this review is to create a fidelity checklist, if one is not already available from the intervention developers. List all the activities in your action plan and put a checkbox next to each activity. 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 4: 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, you should be aware of the need to generate resources to sustain your strategies, beyond the expense of carrying out an intervention.

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. It is important to form a working group of staff and coalition partners to focus on sustainability planning, since getting key stakeholders involved from the beginning can inspire them to become advocates for your work and champions for sustaining your activities.

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

Institutionalizing your work is a long-term process that requires finding ways to make the policies, practices, and procedures you have established become successfully rooted in the community. This includes existing systems and frameworks relevant to your work, which can be stepping stones to eventual policy changes. This can also help extend the length of time you have to work on the issues, since it may take years to build a comprehensive solution. Partnerships are key in finding ways to integrate your work into existing departments within a municipality or into other organizations. 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.

Read more about sustainability here.