Another element of contextual fit that is important to highlight is “cultural relevance” or the fit of the intervention with the values and preferences of implementers, administrators, and those who may benefit. When initially evaluating an intervention (e.g., Phase I, II, III, or IV, Chapter 2), the concern is with its proof of concept, safety, and treatment benefits. The outcome measures selected (see Chapters 14 and 15) should be closely aligned with intervention intent and the proximal and global benefits that may be afforded by exposure to a treatment. However, the outcomes of interest at these phases may not be those of importance to stakeholders and end users downstream at the implementation phase. Thus, striking the right balance and considering ways to align outcomes with a broad range of potential stakeholders are an important challenge to consider early on when developing an intervention.
Value alignment or deriving a fit between the intervention and the values and outcomes sought by different stakeholders is critical to an organization’s willingness to adopt and then implement an intervention. First, it is important to identify all potential stakeholders. Stakeholders may include policy makers, administrators, payers, interventionists, and/or end users or beneficiaries (e.g., individuals and families). Second, it is important to discern each stakeholder’s particular perspective, needs, and values. For example, an agency may be interested in a particular intervention for the following reasons: it addresses an unmet need of the community served; it enhances capacity to deliver needed services; it would provide a market advantage; it may generate a new revenue stream; and/or, it enables the agency to “do the right thing.” Alternately, an interventionist or clinician may be interested in an intervention because it expands and/or enhances his or her own professional skills, or enables him or her to practice in a way that is different from and less confining than his or her traditional practices. Individuals or family members may value an intervention because of the immediate benefits that they experience, such as an improvement in quality of life. Furthermore, policy makers may value only the cost savings generated from an intervention, for example, if it results in fewer hospitalizations or nursing home placements. Identifying each stakeholder’s values leads to what is referred to as a “value proposition” or a concise statement as to why an intervention should be adopted (see Chapter 21).
As noted earlier, in the evaluation phases of an intervention, typically the focus is solely on one form of value—the impact of the intervention on an individual/ family/community (Table 20.3). However, identifying early on the value perspectives of other stakeholders will yield important information that can subsequently inform implementation as one moves forward through the pipeline from testing to implementing an intervention. Obtaining the perspectives of various stakeholders can occur early on in the development of an intervention through, for example, key informant interviews or focus groups.
As illustrated by Hospital at Home, knowledge of stakeholder values and the settings for delivery does not guarantee easy implementation. Other factors including timing, existing payment structures, societal priorities, and trends and policies form the larger context influencing implementation. Also noteworthy is that stakeholder values are dynamic and may change in response to broader policy and societal trends.