To adapt or not to adapt: The association between implementation fidelity and the effectiveness of diabetes self-management education

Louise Schinckus, Stephan Van den Broucke, Gerard van der Zanden, Diane Levin-Zamir, Gabriele Mueller, Henna Riemenschneider, Victoria Hayter, Lucy Yardley, Dean Schillinger, Gerardine Doyle, Kristin Ganahl, Jürgen Pelikan, Peter Chang

Research output: Contribution to journalArticlepeer-review


Self-management education (SME) is a key determinant of diabetes treatment outcomes. While SME programs are often adapted for implementation, the impact of adaptations on diabetes SME effectiveness is not well documented. This study evaluated the impact of the implementation fidelity of diabetes SME programs on program effectiveness, exploring which factors influence implementation fidelity. Data from 33 type 2 diabetes SME program providers and 166 patients were collected in 8 countries (Austria, Belgium, Germany, Ireland, UK, Israel, Taiwan and USA). Program providers completed a questionnaire assessing their adherence to the program protocol and factors that influenced the implementation. Patients answered a pre–post questionnaire assessing their diabetes-related health literacy, self-care behavior, general health and well-being. Associations between implementation fidelity and outcomes were estimated through logistic regressions and repeated measures MANOVA, controlling for potential confounders. Adaptations of the program protocol regarding content, duration, frequency and/or coverage were reported by 39% of the providers and were associated with better, not worse, outcomes than strict adherence. None of the factors related to the participants, facilitating strategies, provider or context systematically influenced the implementation fidelity. Future research should focus on individual and contextual factors that may influence decisions to adapt SME programs for diabetes.

Original languageEnglish
Article number4095
JournalInternational Journal of Environmental Research and Public Health
Issue number8
StatePublished - 13 Apr 2021
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2021 by the authors. Licensee MDPI, Basel, Switzerland.


  • Adaptation
  • Adherence
  • Diabetes
  • Implementation fidelity
  • Intervention effectiveness
  • Self-management education

ASJC Scopus subject areas

  • Pollution
  • Public Health, Environmental and Occupational Health
  • Health, Toxicology and Mutagenesis


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