Journal Article

Exploring fidelity and its influence on effectiveness in an audit and feedback strategy implemented in a low-resource setting: an application of regression modeling

Gloyd, Stephen, Ramiro, Isaias, Gimbel, Sarah, Birru, Ermyas, Sherr, Kenneth, Fernandes, Quinhas, Weiner, Bryan J., John-Stewart, Grace, Augusto, Orvalho, Dinis, Aneth, Uetela, Dorlim

2025

Overview

Background Assessing implementation fidelity—the degree to which a program is implemented as intended—is essential to understand whether poor outcomes are due to implementation problems or the design of an intervention. Few studies in health research have documented the association between implementation fidelity and effectiveness. The Integrated District Evidence-to-Action (IDEAs) is a multicomponent audit and feedback strategy designed to improve the implementation of maternal and child clinical guidelines in Mozambique. In a previous study, we found mixed results of IDEAs effectiveness. The objective of the present study is to understand how implementation fidelity may have influenced the effectiveness of the strategy. Methods IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces in Mozambique between 2016 and 2020. We used the conceptual framework for implementation fidelity to guide descriptive analysis of IDEAs adherence. Regression modeling was used to study patterns of the direction of association between measures of fidelity and effectiveness for ten service delivery outcomes and five service readiness outcomes. Results We describe adherence on 15 measures of fidelity, of which 12 had high fidelity. Poor fidelity was found in conducting facility service readiness assessments and completing micro-interventions from action plans. Service delivery measures tended to be positively associated with participation and degree of micro-intervention completion and negatively associated with a higher number of action plans elaborated by participating teams. For the service readiness outcomes, delivery of essential care was positively associated with participation and micro-intervention completion, and staff availability was negatively associated with supervision. Conclusion Participation in audit and feedback meetings, the number of action plans elaborated, and the degree of completion of micro-interventions seem to be related to the effectiveness results. IDEAs should be adapted to reduce the number of action plans elaborated and promote better micro-intervention completion. Additionally, combining audit and feedback strategies with other strategies might enhance effectiveness in service outcomes. This study examines how to analyze the link between fidelity and effectiveness of a strategy to inform better design and recommend context-specific improvements.

• Publisher: BioMed Central,Springer Nature B.V,BMC
• Subject: Audit and feedback / Audits / Charitable foundations / Design / Effectiveness / Feedback / Health Administration / Health facilities / Health Policy / Health Promotion and Disease Prevention / Health Services Research / Implementation fidelity / Implementation Science / Infant mortality / Information systems / Intervention / Maternal and Child Health / Medicine / Medicine & Public Health / Meetings / Mozambique / Primary care / Professional practice / Public Health / Supervision / Workforce planning