Applying an equity lens to characterizing the process and reasons for an adaptation to an evidenced-based practice

BACKGROUND: Adaptations to evidence-based practices (EBPs) are common but can impact implementation and patient outcomes. In our prior research, providers in routine care made a fidelity-inconsistent adaptation to an EBP that improved health outcomes in people with serious mental illness (SMI). The purpose of this study was to characterize the process and reasons for the adaptation using a framework for reporting adaptations and modifications to EBPs, with a focus on equity. METHODS: This study used qualitative data collected during a national implementation of the InSHAPE EBP addressing obesity in persons with SMI. We reviewed transcripts from five behavioral health organizations that made a successful fidelity-inconsistent adaptation to a core component of InSHAPE that was associated with cardiovascular risk reduction. We coded the data using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) with an emphasis on exploring whether the adaptation addressed inequities in using the EBP related to social determinants of health. RESULTS: Across the five agencies, the fidelity-inconsistent adaptation was characterized as unplanned and reactive in response to challenges InSHAPE teams experienced delivering the intervention in community fitness facilities as intended. In all cases, the goal of the adaptation was to improve intervention access, feasibility, and fit. Social and economic disadvantage were noted obstacles to accessing fitness facilities or gyms among participants with SMI, which led agencies to adapt the program by offering sessions at the mental health center. CONCLUSION: Findings from this study show the advantages of applying a health equity lens to evaluate how obstacles such as poverty and discrimination influence EBP adaptations. Recommendations can also assist researchers and community partners in making proactive decisions about allowable adaptations to EBPs. PLAIN LANGUAGE SUMMARY: Adaptations to evidence-based practices (EBPs) are common but can impact implementation and patient outcomes. Understanding why adaptations are made to EBPs by organizations and providers during implementation can help inform implementation strategies designed to guide adaptations that improve outcomes. We found that social and economic factors were driving inequities in access to a core intervention component of an EBP, which led agencies to adapt an EBP in a way that model developers considered to be inconsistent with fidelity but improved patient outcomes. These findings contribute to the growing literature on equitable implementation and adaptation by highlighting the advantages of considering when and how fidelity-inconsistent adaptations to an EBP may be in the service of reducing inequities in access to and use of EBPs for health disparity groups.