Flexibility within fidelity: A narrative review of practitioner modifications to child welfare interventions

Purpose: Although there is a growing number of evidence-based interventions in child welfare, their outcomes are impacted by the level of implementation fidelity. Research demonstrates that it is vital to understand the type and degree of adaptations and modifications made during implementation. This narrative review examined articles where child welfare practitioners implemented an intervention. It analysed how practitioners modified the intervention, their reasons for the modification, and the effects on fidelity. Understanding the commonalities and reasons for these modifications will enhance the likelihood of successful implementation in child welfare systems.

Design and methods: A systematic search was conducted using the Applied Social Sciences Index & Abstracts (ASSIA), ERIC, International Bibliography of the Social Sciences (IBSS), Social Science Database, and Social Services Abstracts electronic databases. The search was limited to qualitative and mixed-methods journal articles in the English language. The search terms were “evidence-based”, “evidence-informed”, “research informed”, “empirically supported”, “evidence-supported” and “implement”, with derivations such as implementation, and “child protection”, “child welfare”, or “protective services”.

Studies were included if their focus was on practitioners implementing an intervention in a child welfare setting. Studies were excluded if their focus was not on child welfare; if they were non-research articles, theses/dissertations, or interventional studies; or if the focus was not on the process of implementation. The data were extracted into a matrix based on the Framework for Reporting Adaptations and Modifications-Expanded (FRAME).

Results: Seventeen articles based on 15 studies were reviewed. All the studies reported some form of modification to the intervention by practitioners. Two main categories of modifications were identified: those based on practitioners’ needs and those based on client needs. Practitioners were highly focused on enhancing the feasibility of interventions to help manage their large workloads. Practitioners also valued client relationships and prioritised those relationships over fidelity. Few interventions addressed the complex needs of child welfare clients, leading to further adaptation. Fidelity was most influenced by practitioners holding a conceptual understanding of the intervention and its core principles. These practitioners made thoughtful adaptations to enhance the intervention without affecting fidelity.

Practice implications: The findings showed clear gaps in research. Further research should report on practitioner modifications and measures of fidelity, study the minimum length of effectiveness for interventions, and focus on developing interventions that address multi-morbidity. Finally, the findings showed that the primary barriers for practitioners using interventions with fidelity were organisational barriers. Practitioners were unlikely to use interventions when balancing too many competing priorities.