Fidelity matters: Implementing ADS Plus, an evidence-based program, in multiple adult day service sites

Background and Objectives In a cluster randomized trial, we found that augmenting adult day services (ADS) with a multicomponent caregiver support program, ADS Plus, reduced caregiver depressive symptoms and increased ADS use. Unclear is whether the program was implemented with fidelity across sites and the relationship of fidelity to site characteristics and caregiver outcomes. Research Design and Methods Sixteen ADS sites were randomly assigned to ADS Plus (n = 102 caregivers), which offered dementia education, referrals/linkages, validation/support, and strategies for self-care and caregiver-identified challenges. Sites were categorized with high, moderate, or low fidelity based on the number of caregivers enrolled (delivery), care challenges addressed, and prescriptions (strategies) provided (receipt). We examined staff documentation of delivery, receipt, and enactment characteristics, the relationship of fidelity to site characteristics, and caregiver outcomes (depressive symptoms, stress) collected by interviewers 3, 6, and 12 months postbaseline. Results Of 102 caregivers, 79.5% were in high (n = 58, 56.9%) or moderate (n = 23, 22.6%), versus 20.6% (n = 21) in low-fidelity sites. High/moderate versus low-fidelity sites delivered more sessions and spent less preparatory time. Caregiver receptivity to sessions was high across all sites. Caregivers with enactment data (n = 43) reported reduced difficulties and upset in high/moderate fidelity sites, and enhanced confidence managing care challenges in high-fidelity sites (p <. 0001). Sites with higher percentages of White, non-Hispanic families (p =. 006) and dementia clients (p =. 004) had better fidelity. At three and 12 months but not at 6 months, caregivers in high/moderate fidelity sites had greater reductions in depressive symptoms and stress (p<.05) compared to those in low-fidelity sites. Discussion and Implications Most caregivers received ADS Plus with moderate to high fidelity. High/moderate fidelity sites delivered more sessions to more caregivers with substantially stronger caregiver benefits. As fidelity varied by site characteristics, adaptations to staff training and the program appear needed for low-fidelity sites.