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Modern health and welfare services are increasingly characterized by standardized methods and growing demands for services to be grounded in scientific findings. At the same time, professionals are expected to exercise judgment to meet individual needs. This thesis explores how this tension manifests in the way that professionals navigate fidelity–adaptation dilemmas while providing parenting programs in community settings in Sweden. 

Through a combination of qualitative interviews and a discrete choice experiment, this thesis examines (1) the circumstances that trigger adaptations, (2) the nature and consistency of modifications made to programs, and (3) how professionals weigh different outcomes when making adaptation decisions. 

The findings demonstrate that fidelity–adaptation decisions are pervasive and dynamic, occurring even in well-implemented programs. Study I identifies 11 distinct reasons facilitators recognize for making adaptations. Study II reveals that practitioners’ capacity to make thoughtful adjustments while maintaining program integrity varies considerably. Study III illuminates the breadth of outcomes valued by providers and recipients, highlighting the complex multi-goal context of program delivery. Study IV quantifies how professionals prioritize these different outcomes and finds that relationship quality most strongly influences adaptation decisions.

The findings demonstrate that fidelity–adaptation decisions are pervasive and dynamic, occurring even in well-implemented programs. These decisions reflect the complex interplay between practitioners’ professional judgment, working conditions, and organizational demands. This thesis shows how practitioners actively negotiate competing professional demands in their daily work, demonstrates how organizational contexts and governance structures shape professional discretion, and highlights the importance of creating supportive work environments that enable practitioners to make informed decisions while managing multiple organizational goals. These insights suggest that sustainable implementation requires approaches that recognize and support practitioners’ professional agency while acknowledging the complex organizational realities in which they operate.