Fidelity and acceptability of implementation strategies developed for adherence to a clinical pathway for screening, assessment and management of anxiety and depression in adults with cancer
Authors: He Sharon , Shepherd Heather , Butow Phyllis , Shaw Joanne , Harris Marnie , Faris Mona , Girgis Afaf ,   The ADAPT Program Group, Beale Philip , Butow Phyllis , Clayton Josephine , Cuddy Jessica , Davies Fiona , Dhillon Haryana , Faris Mona , Geerligs Liesbeth , Girgis Afaf , Grimison Peter , Hack Thomas , Harris Marnie , He Sharon , Kelly Brian , Kelly Patrick , Kirsten Laura , Lindsay Toni , Lovell Melanie , Luckett Tim , Masya Lindy , Murphy Michael , Newby Jill , Piro Don , Price Melanie , Rankin Nicole , Shaw Joanne , Shaw Tim , Shepherd Heather , Viney Rosalie , Yim Jackie , Rankin Nicole 
Published: May 2024

Abstract
Background
Implementation strategies are crucial to facilitate implementation success. To prepare and support implementation of a clinical pathway for screening, assessment and management of anxiety and depression in cancer patients (the ADAPT CP), six broad categories of implementation strategies; (1) Awareness campaigns, (2) Champions, (3) Education, (4) Academic Detailing and Support, (5) Reporting, (6) Technological Support, were developed. The aim of this paper is to describe the fidelity and acceptability of six categories of implementation strategies and any subsequent changes/adaptations made to those strategies.

Methods
The ADAPT CP was implemented in twelve cancer services in NSW, Australia, as part of a cluster randomised controlled trial of core versus enhanced implementation strategies. Fidelity to and any subsequent changes to the delivery of the planned six categories of implementation strategies were captured using the ADAPT contact log, which recorded the contacts made between the ADAPT research team and services, engagement meetings and monthly meetings. To explore acceptability and awareness/engagement with the implementation strategies, interviews with a purposively selected staff sample across both study arms were held prior to implementation (T0), six months into implementation (T1) and at the end of the 12-month implementation period (T2). Interviews were thematically analysed across the six categories of strategies.

Results
Delivery of all six categories of implementation strategies as planned was moderated by service context and resources and staff engagement. As such, for some implementation strategies, subsequent changes or adaptations to the content, mode of delivery, frequency and duration such as abbreviated training sessions, were made to optimise fidelity to and engagement with the strategies. Most strategies were perceived to be acceptable by service staff. Use of strategies prior to implementation of the ADAPT CP such as the engagement meetings and training sessions, positively impacted on ownership and preparedness to implement the ADAPT CP. Furthermore, ongoing support such as provision of additional training or monthly meetings facilitated increased awareness and engagement with the ADAPT program.

Conclusion
Flexibility in delivering implementation strategies, and ensuring staff engagement with, and acceptability of those strategies, can support implementation of interventions within healthcare settings.

Trial registration
The ADAPT CRCT was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372486&isReview=true