Although each of the eight elements that form a composite understanding of contextual fit are important to consider, we would like to highlight in particular the role of “skills/competencies” of interventionists. Identifying who can deliver an intervention is an important consideration and decision that typically occurs early on in the pipeline when developing a program (see Chapter 5). As these cases illustrate, the availability of interventionists with the requisite skills and competencies is an important challenge impacting implementation potential.
In classic Phase III efficacy trials, tradition has it that “super” clinicians or interventionists are selected for intervention delivery as the goal at this phase is to optimize internal validity and the potential for treatment benefits. However, this practice has significant downstream consequences with respect to wide-scale program implementation. If only certain professional groups can deliver the intervention, and within that group, only elite clinicians, then the replication potential of a proven program may be significantly reduced. Also, training in a proven program will then need to be adjusted to account for greater variation in skills and competencies that exist in the larger population of potential interventionists.
As illustrated by both Skills2CareR and GBGB, dependence upon highly skilled personnel drives up the cost of an intervention and may limit its potential reach and adoption in settings that do not have access to such personnel. This is not to say, however, that interventions should be designed for delivery only by interventionists who reflect a common denominator or simplified skill set; clearly, the competencies of interventionists must reflect the needs and purposes of an intervention. However, knowledge of the potential challenges presented by the skill sets needed should be noted early on in intervention development as it will affect downstream issues related to the potential reach of an intervention, its ease of adoption by agencies and organizations, and the scope and nature of training that may be necessary.
Still, concern with using highly skilled and costly personnel for intervention delivery and also the need to reach populations not traditionally included in behavioral intervention research have promoted an interest among researchers in examining the role of community health workers (CHWs) and/or peers. CHWs are indigenous workers who share similar backgrounds (ethnicity, language, or geography) as the population being targeted by an intervention (Han et al., 2015). In this respect, they may be uniquely qualified ethnically, linguistically, socioeconomically, culturally, and/or experientially to deliver an intervention. This may be the case in particular when designing interventions for underserved and diverse populations that have limited access to present health and human services owing to economics, culture, and language. Use of peers and CHWs may appear to be cost-effective, although as use of this group would necessitate potentially more intensive training, oversight, and monitoring, cost efficiencies may not be fully realized as initially expected. Interventions delivered by peers/CHWs for chronic disease self-management, cancer detection, and depression demonstrate preliminary support for this approach (Han et al., 2015). Clearly, however, the CHW model for interventions would not be appropriate when highly skilled health and human service professionals are needed such as in Skills2CareR or the Hospital at Home model; nevertheless, the delivery of elements of each of these approaches may be possible. For example, some portions of the Hospital at Home model may be delivered by CHW such as patient education, assistance with self-care needs, and so forth. For Skills2 CareR, once an action plan has been established by a skilled interventionist (an occupational therapist), peer mentors may be able to practice the strategy with family caregivers. However, such deviations to these evidence-based programs would need careful evaluation.
In summary, a highly manualized intervention (see Chapter 6) may require a less skilled interventionist, which may in turn enhance precision and implementation potential. Interventions requiring a high level of skill and/or clinical reasoning may be necessary, but they may drive up cost and potentially limit adoption by organizations with limited resources and/or access to staff with the needed competencies. These are the trade-offs that need to be thoughtfully considered early on when developing an intervention in the crucial period of discovery as discussed in Chapter 3.