Advisor(s)

Matthew Fifolt

Committee Member(s)

Andrea Cherrington
Anne Brisendine
Kimberly Smith
Larry Hearld
Olakunle Alonge

Document Type

Dissertation

Date of Award

1-27-2026

Degree Name

Doctor of Public Health (DrPH)

School

School of Public Health

Department

Public Health

Abstract

Intervention outcomes cannot be fully understood without examining how implementation strategies are delivered. While implementation fidelity to interventions is well recognized as a determinant of effectiveness, the fidelity of implementation strategies—the methods used to support intervention adoption—remains under-documented and under-assessed. Without this information, it is difficult to contextualize why interventions succeed or fail across diverse settings. This three-paper dissertation focuses on practice facilitation (PF), a widely used strategy in primary care quality improvement, as implemented in the Heart Health Improvement Project (HHIP) in Alabama. HHIP, led by the Alabama Cardiovascular Cooperative and funded by the Agency for Healthcare Research and Quality, aimed to improve blood pressure (BP) control and tobacco use screening/cessation among 47 under-resourced primary care practices. Practices participated in a 12-month PF-supported intervention guided by a detailed protocol. A fidelity checklist was developed using the Conceptual Framework for Implementation Fidelity to capture adherence (composite score across four protocol components: monthly data checks, Key Driver Implementation Scale completion, quality improvement activity completion, and PF contacts) and exposure (contact frequency and duration). Clinic characteristics, implementation characteristics, and BP outcomes were also assessed. Results showed substantial variability in PF fidelity: the mean composite adherence score was 33/40, but only 9% of clinics achieved complete adherence. Higher adherence was linked to more in-person/virtual contacts and greater total interaction time. Exploratory analyses indicated that higher PF fidelity may relate to greater BP control improvements, though effects varied by racial/ethnic group. Organizational characteristics did not predict adherence but influenced PF exposure (frequency and duration). Understanding the “how well” of implementation strategies like PF is critical to explaining outcome variation, strengthening the evidence base, and guiding the equitable and sustainable translation of interventions into practice. Future work should refine fidelity metrics, explore contextual moderators, and integrate continuous fidelity assessment into implementation design to maximize impact.

Keywords

cardiovascular health;implementation strategy fidelity;practice facilitation;primary care;quality improvement

ProQuest Publication Number

32171037

ISBN

9798273349551

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