What does contextual fit look like in practice?
Examples of the impact that contextual fit can have on implementation are available in every discipline. Consider one intervention focused on reducing substance abuse developed in the Midwest that emphasized both the development of after-school community activities and family support. The intervention had been used with significant success in two midwestern states and was highly anticipated by community organizers in an urban west coast context. Unfortunately, there was no effort to assess whether the roles, responsibilities, and specific strategies of the intervention were valued by and culturally comfortable with the families, youth, or local professionals. The poor match between the vision that parents in the host city had for themselves and the expectations of the intervention led to both poor-quality implementation and no change in substance abuse levels. (Additional examples in brief, pages 8-9.)What are the policy implications of contextual fit?
One reason contextual fit has received muted attention is that there is no accepted approach for how to measure it. Horner and colleagues (2003) provide one possible approach in their 16-item assessment of contextual fit (each item is rated on a 6-point Likert-like scale). Although this self-assessment has been used in studies assessing the contextual fit of behavior support plans in school, home, and community settings, and the resulting outcome score has been correlated with fidelity of implementation, it has not been extended to studies or interventions outside of education. Currently, no contextual fit measure with documented psychometric properties can be used to evaluate the implementation of a broad range of evidence-based interventions across educational, mental health, juvenile justice, and community contexts. (More information in brief, pages 9-10.)What are the research implications of contextual fit?
For contextual fit to assume the role it is touted to fill in implementation science, a concerted effort is needed to build a solid empirical foundation. Three initial steps for future research are needed: (a) developing technically adequate measures of contextual fit, (b) documenting the role of contextual fit in the effectiveness and efficiency of implementation, and (c) determining the extent to which questions of contextual fit can be used to assess readiness for implementation. (Details in brief, page 11.)Intervention Elements
“Intervention” refers to a procedure, or set of procedures designed for use in a specific context (or set of contexts) by a specific set of users to achieve defined outcomes for (a) defined population(s).Need
1a. Is the outcome of the intervention highly valued?
1b. Is the level of current success low enough that there is a need for something different according to:• Those receiving support (children, youth, families, clients)• Those providing support• Those responsible for effective support (administrators, community members, political leaders) Precision
2a. Is the proposed intervention defined with clarity and is detail provided to determine what is done, by whom, when, and why? Are core features defined? Are strategies for achieving the core features defined?An Evidence-Base
3a. Does empirical evidence exist that the implementation of the core features results in valued outcomes? Does the evidence document the target population, setting conditions, and usability conditions in which valued outcomes were achieved?Efficiency
4a. Are the time and effort for initial adoption reasonable?
4b. Are the time and effort for sustained adoption as efficient or more efficient than current interventions (given the outcomes generated)?Skills/Competencies
5a. Are the skills needed to implement the intervention defined?
5b. Are materials and procedures available to establish needed skills?
5c. Does the level of skill development fit professional standards and or the organizational staffing structure?Cultural Relevance
6a. Are the outcomes of the intervention valued by those who receive them?
6b. Are the strategies and procedures consistent with the personal values of those who will perform them?
6c. Are the strategies and procedures consistent with the personal values of those who will receive them?Resources
7a. What time, funding, and materials are required for initial adoption?
7b. What training, coaching, and performance feedback are needed for high-fidelity implementation?
7c. What time, funding, and materials are required for sustained adoption?
7d. What fidelity measures are needed to ensure monitoring of an implementation?Administrative/Organizational Support
8a. Is adoption of the intervention supported by key leaders?
8b. Will adoption of the intervention be monitored by key leaders?
8c. Will fidelity and impact of the intervention be monitored by key leaders?
8d. Is there a documented commitment to make the intervention a standard operating procedure?Process Elements
Contextual fit influences the implementation process at three points. Selection EBI
An intervention should match the skills, values, and resources of those in the implementation context—that is, those who are providing, supporting, and receiving the intervention. Initial Implementation of EBI
The way an intervention is introduced can determine whether it is accepted and adopted by both the community and service providers. The timing, amount, format, and integration of training into an existing service setting can affect the likelihood that the new intervention will be implemented well and yield positive results.Ongoing Implementation and Scaling Up of EBI
The sustained use of an intervention may depend on implementers’ ability to continually adapt the intervention as conditions in the setting evolve. Adaptations need to be developed with full consideration of the extent to which they “fit” with the skills, values, and resources of those who use and benefit from the intervention.
"Change starts with one person and can grow really fast." - Tristan