Adaptations and modifications to a co-designed intervention and its clinical implementation: a qualitative study in Denmark
Open accessAbstract
Background: There is a long-standing debate in implementation research on whether adaptations to evidence-based interventions (EBIs) are desirable in health care. If an intervention is adapted and not delivered as conceived and planned, it is said to have low fidelity. The WALK-Cph project was developed based on the assumption that involving stakeholders in co-design processes would facilitate the fidelity of an intervention to increase the mobility of acutely admitted older medical patients and its implementation in two hospitals in Denmark. The purpose of this study is to describe and analyse adaptations and modifications that were made to the co-designed WALK-Cph intervention and its implementation. Methods: This study used a qualitative design. An ethnographic field study was performed using participant observations, workshops and semi-structured interviews. Data were analysed twice using the Framework Method. The first analysis was based on the frameworks from Stirman, Moore and Proctor. The second analysis, a retrospective modifications analysis, was based on the Adaptation-Impact Framework. Results: Many different types of adaptations and modifications were made to the WALK-Cph intervention and its implementation plan. Most of the modifications were made on the contents of the intervention. In total, 44 adaptations and modifications were made, of which 21 were planned (adaptations) and 23 were made haphazardly (modifications). Most of the content and context adaptations and modifications made on the intervention had a mixed result regarding enhanced fidelity. The retrospective modifications analysis showed that modifications were ongoing and both situationally and contextually shaped. Conclusions: Although an extensive co-design process was carried out to facilitate the fidelity of the WALK-Cph intervention, this study showed that many adaptations and modifications were still made to both the intervention and its implementation plan. It could indicate that the co-design process had a small effect or that adaptations and modifications are ongoing and both situationally and contextually shaped, which challenge the assumption and the desire to be able to plan and control changes.
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As Roper et al. (2022) did not assess the quality of PD-specific adaptations to psychotherapies in the included studies, it offered limited insight into their potential fit to the context in which practitioners will use the interventions.
“Additionally, as the review did not assess the quality of PD-specific adaptations to psychotherapies in the included studies, it offered limited insight into their potential fit to the context in which practitioners will use the interventions (Kirk et al., 2021).”
From A Systematic Review of Third-Wave Therapies to Reduce Distress and Improve Wellbeing and Quality of Life in People with Parkinson's Disease. (2025) · cites this paper as Kirk et al., 2021
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- [61]Morse J Reframing rigor in qualitative inquiry The SAGE Handbook of Qualitative Research 2018 Den Zin and Lincoln SAGE Publications, Inc
- [77]Fonseca J Conplexity and innovations in organizations 2002 London and New York Routledge
- [82]Tjørnhøj-Thomsen T. In: Hastrup K, editor. Samværet. Tilblivelse i tid og rum. I: Ind i Verden. En grundbog i antropologisk metode,Kap. 5. pp. 93-116. Hans Reitzels Forlag, 2.udgave, 1.oplag. vol. 2010. Denmark: Hans Reitzels Forlag; 2010. ISBN-13: 978-87-412-2425-1.
Cited by
Sorted by citations
Implementation Insights from the PEACE Pathway Across UK Eating Disorder Services
Tchanturia, K., Chubinidze, D., Duffy, F., Nimbley, E., Li, Z., & Holliday, J. (2025) · Nutrients · doi:10.3390/nu17091532 · Cited by 14 · see citing works
“This is consistent with findings from other intervention studies, where adaptations to interventions often occur in response to contextual changes and evolve iteratively [45].”
Faro, E. Z., Jones, D., Adeagbo, M. J., Cho, H., Swartzendruber, G., Tabb, K. M., Tandon, S. D., & Ryckman, K. K. (2024) · Implementation Science · doi:10.1186/s13012-024-01402-7 · Cited by 5 · see citing works
“Three-variable hybrid designs, while relatively new, seek to make explicit what many hybrid implementation effectiveness trials already do implicitly, which is take into account the role of contextual determinants in implementation [46–48].”
BackgroundChristodoulou, D., Reeves, S., Carvalho, N. P., Stellman, J., & Gould, R. L. (2025) · Clinical Gerontologist · doi:10.1080/07317115.2025.2511957 · Cited by 4 · see citing works
“Additionally, as the review did not assess the quality of PD-specific adaptations to psychothera-pies in the included studies, it offered limited insight into their potential fit to the context in which practitioners will use the interventions (Kirk et al., 2021).”
McGowan, D., Morley, C., Hansen, E., Shaw, K., & Winzenberg, T. (2025) · Health Expectations · doi:10.1111/hex.70436 · Cited by 4 · see citing works
“Team membership turnover and its effects have been commonly reported in other co ‐ design studies [21, 24, 33 – 37].”
Tracey, I., Gomes, E., Signal, N., Alder, G., Forch, K., & Olsen, S. (2025) · JSAMS Plus · doi:10.1016/j.jsampl.2025.100120 · Cited by 2 · see citing works
“Although person-centred care is a cornerstone of rehabilitation [54], the under-reporting of personalisation strategies may reflect an effort to reduce confounding factors in intervention protocols [55].”
Provvidenza, C., Al-Hakeem, H., Ramirez, E., Rusyn, R., Kingsnorth, S., Marshall, S. A., Mallory, K. D., & Scratch, S. (2024) · PEC Innovation · doi:10.1016/j.pecinn.2024.100299 · Cited by 2 · see citing works
“Adaptation entails making planned or purposeful changes to the information in an intervention or how an intervention is delivered [30].”
BackgroundDonnelly, M. R., Liew, S.-L., & Jolles, M. P. (2026) · Journal of Occupational Science · doi:10.1080/14427591.2026.2615275 · Cited by 1 · see citing works
“Some implementation science researchers draw on the concept of core functions and forms from complex systems theory to better understand, map, and evaluate the implementation of multi-level interventions (Kirk et al., 2020, 2021; Pérez Jolles et al., 2019).”
Setswe, G., Day, S., Ndebele, F., Pienaar, J., Ncube, V., & Feldacker, C. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-091934 · Cited by 1 · see citing works
Sivertsen, D. M., Becker, U., Andersen, O., & Kirk, J. W. (2024) · Nordic Studies on Alcohol and Drugs · doi:10.1177/14550725241252256 · Cited by 1 · see citing works
“This could be due to contextual factors and the fact that interventions need to be adapted or tailored to the local context (Kirk et al., 2021; Waltz et al., 2019; Wensing et al., 2011).”
BackgroundSelf-citationSykes, M., O'Mahony, L., Wiggin, D. A., & Timmons, S. (2023) · BMC Health Services Research · doi:10.1186/s12913-023-10019-3 · Cited by 1 · see citing works
“Consistent with the idea of core and peripheral components [4], we found that, as within the English context, the intervention supported the commitment and informational assessment of participants to undertake actions to improve performance described in the national audit.”
BackgroundResultHoffman, S. J., Fredkove, W. M., Voller, V., Broderick, P. C., Moo, H., Davis, A., & Gewirtz, A. H. (2026) · Global Health Promotion · doi:10.1177/17579759261443506
Elepaño, A. G., Tan‐Lim, C. S. C., Bankhead, C. R., Dans, L. F., Fabian, N. M. C., Sanchez, J. T., Dans, A. L., & Pope, C. J. (2026) · JMIR Formative Research · doi:10.2196/69874
“Importantly, adaptation after implementation is not a failure mode as even co-designed interventions are routinely modified during real-world implementation to maintain fit and effectiveness [36].”
Poulsen, L. K., Clausen, M. B., Mørkeberg, C. J. P. W. S., & Kirk, J. W. (2025) · Disability and Rehabilitation · doi:10.1080/09638288.2025.2590434
“This external attribution of responsibility is a well-documented phenomenon in collaborative research and can present a barrier to implementation, as decision-makers become distanced from those responsible for enacting [13,44].”
Self-citationSite‐initiated adaptations in the implementation of an evidence‐based inpatient walking program
Hughes, J. M., Choate, A., Meyer, C., Kappler, C. B., Wang, V., Allen, K., Houtven, C. V., Hastings, S. N., & Zullig, L. (2024) · Journal of The American Geriatrics Society · doi:10.1111/jgs.19044
“15,16 In anticipation, STRIDE proactively encouraged flexibility in this area by offering different staffing models to STRIDE sites as part of the pre-implementation planning process.”
- Authors
- Kirk, J. W., Nilsen, P., Andersen, O., Stefánsdóttir, N. T., Grønfeldt, B., Brødsgaard, R., Pedersen, B. S., Bandholm, T., Tjørnhøj-Thomsen, T., & Pedersen, M. M.
- Affiliations
- Aarhus University (DK)
- Amager Hospital (DK)
- University of Copenhagen (DK)
- Corresponding author
- Kirk, Jeanette Wassar
- ORCID
- Venue
- BMC Health Services Research
- Published
- 2021-10-16
- Volume
- 21
- Issue
- 1
- Pages
- 1108-1108
- ISSN
- 1472-6963 (ISSN-L)
- PMC
- PMC8520628
- OpenAlex
- W3207603336
- Cited by
- 21
- References
- 90
- Citations by year
- 2026: 4 · 2025: 7 · 2024: 6 · 2023: 4
- FWCI
- 2.81
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Health Services Research (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research at the University of Copenhagen (University of Copenhagen) (publishedVersion, cc-by)
- University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion, cc-by)
- DiVA (Linkoping University) (submittedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Velux Fonden (F-21835-01-04-03)
- Danske Fysioterapeuter (PD-2018-30-10)
- Region Hovedstaden (P-2018-2-11)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Keywords
- intervention adaptation, co-design, implementation fidelity, evidence-based interventions, older medical patients, mobility (physical function), acute hospital care, stakeholder engagement, clinical implementation, framework method
- MeSH terms
- Delivery of Health Care, Denmark, Humans, Research Design, Retrospective Studies, Qualitative Research
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