Facilitators and Barriers to Implementation of Manualized Interventions in Community Based Settings

Background: The Caregiver Skills Training (CST) Program aims to provide evidence-based skills training for caregivers of children with autism in community settings. The program was developed by the World Health Organization using a systematic approach engaging stakeholders globally in the design and now field testing and scaling up the program, including community organizations, government, advocates, and researchers in over 30 countries.

Objectives: In the Canadian adaptation of the CST Program, we focused on measuring facilitators and barriers of implementation within community settings. We formed a Community of Practice (CoP), a dynamic social participative approach to learning and discovery previously used in health research. The CoP brought together professionals involved in early intervention.

Methods: Professionals in public sector and community health and educational services involving children with autism (n=15) participated in Community of Practice over a one year period. At baseline, the participants received 35 hours of training on the intervention model and self-rated their confidence in implementation of the intervention in their own setting: (a) continue to train towards fidelity, (b) use the intervention and/or specific strategies in routine practice, or (c) coach others in the same setting. Three follow up sessions were completed with the CoP to assess change in practice and to discuss facilitators and barriers to implementation.

Results: By the end of the follow up period, only one professional had continued to train to fidelity and none of the professionals had implemented the intervention. Qualitative analysis of CoP sessions was conducted to ascertain barriers to implementation. Reported barriers include limited time to attain fidelity, limited time available with each family to deliver the full intervention, inconsistency in some of the intervention characteristics relative to the target setting, and limited support from management in adopting the new intervention. However, participants reported indirect influence of intervention strategies including improved understanding and capture of “shared engagement” and “play” and increased consolidation of routine strategies reinforced in the intervention.

Conclusions: Despite intention to do so, professionals who trained on a manualized intervention did not exhibit a direct change in practice as a result of the training. In contrast, indirect influence on practice was reported, yielding more general and positive improvements in practice as reported by professionals.