The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 4
4 - Usable
The intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components
Core Components
Mindfulness Based Stress Reduction (MBSR) is a standardised intervention that focuses on training in mindfulness approaches, with an emphasis on coping with stress and promoting adaptive health behaviours (including adjusting to chronic conditions). This group-based intervention can be delivered to adults, adolescents and school-aged children to address a range of physical and psychological conditions, including depression, anxiety, substance use, stress and burnout).
MBSR is a group-based therapy, a brief economic analysis of groups delivered in Scotland indicated that three people can be treated with MBSR for the same staff resource as one person in individual therapy, offering the possibility of reduced waiting times(1).
MBSR is usually delivered over 8 weekly in-class sessions, each lasting between 2 to 2.5 hours. It includes weekly homework practices to enhance learning and can include a day-long meditation retreat. The sessions teach mindfulness practices that include mindfulness meditation on the breath, a body scan practice focusing on awareness of body sensations, mindful movement practice (based on gentle yoga or similar practices) and the application of mindful awareness in everyday life. This is integrated with an understanding of stress from mind-body medicine and psychological understanding of how humans create experiences of distress and build resilience. The intervention aims to enhance awareness of present-moment experience, with increased acceptance and reduced reactivity / judgement. Individuals learn to step out of “automatic pilot” (where we are more likely to react unhelpfully to experience) and to inhabit more a state of “being” in awareness (where we have more choice in how we respond). This leads to reduction in rumination and worry, as well as enhancement in self-esteem, self-regulation, psychological resilience and life satisfaction.
Fidelity
Fidelity is enhanced through a range of competency criteria which includes observation / mentorship (through an apprenticeship model of training). Formal fidelity tools include the Mindfulness Based Intervention – Teaching Assessment Criteria (MBI-TAC) (developed by Bangor Centre for Mindfulness) for observational feedback or self-reflection.
Training should follow an established / validated pathway meeting the Good Practice Guidelines established by BAMBA (British Association of Mindfulness Based Approaches). The NHS Education for Scotland Mindfulness Network has developed a local training pathway to meet the needs of NHS staff / services. It provides a listing of therapists who have completed the expected pathway and encourages an apprenticeship model where training and supervision is offered locally in Health Boards. The Scottish Mindfulness Network is a member of BAMBA and maintains links to this UK based charity to inform training, supervision and professional development of mindfulness therapists.
Modifiable Components
The MBSR protocol can be modified to increase disorder specificity. MBSR can be delivered in a number of settings (e.g., prisons, schools, community and health-care settings, and corporate environments) for a variety of physical and mental health conditions including stress. In addition to face-to-face delivery, MBSR can be delivered on-line (using a secure platform) with a growing evidence base of its effectiveness. MBSR has also been adapted using a range of structured self-help resources (e.g. via apps, books and audio). These may provide a useful adjunct to other forms of therapy. However, an 8-week face-to-face (or line) course is the “gold standard” in terms of effectiveness.
Children and young people - Anxiety - Rating: 4
Usable - this intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components.
Adults - GAD & Panic - Rating: 4
Usable - the intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components.
Adults - Chronic Pain - Rating: 4
Usable - the intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components.
Adult - Substance Use - Rating: 4
Usable - the intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components.
Supports - Rating: 3 - 4
Support for Organisation / Practice
Implementation Support
Implementation support can be provided primarily by the NHS Scotland Mindfulness Network (supported by NHS Education for Scotland). This is led by two coordinators (Neil Rothwell and Charlotte Procter) who oversee the Scotland wide network and Mindfulness Leads in each Health Board area (Scottish NHS Mindfulness Network), many of whom will be experienced at delivering training and supervision.
In addition, there are national organisations that guide the practice, teaching and development of mindfulness-based approaches and set standards around training and supervision. These include BAMBA (British Association of Mindfulness Based Approaches) and The Mindfulness Network (UK), who offer supervision, professional development and training. There are a number of additional training organisations (University, private or charity based) that can offer training, supervision and continuing professional development (many of which will be affiliated training organisations within BAMBA).
Implementation support for the delivery of on-line interventions should also include access to a suitable, secure platform which has been approved by the local Health Board. The platform should ideally have the option of break-out rooms.
Start-up Costs
Training in MBSR is provided at no cost if available through local NHS Health Board areas. This is dependent upon the availability of trainers (mindfulness therapists who have been trained to deliver a training) and their capacity to be made available to conduct training. Health Board areas may share resources / expertise to deliver training jointly. Staff will be able to complete the 8-week MBSR course at no cost if there are staff places available in patient focussed groups.
Costs will apply for training by private providers, if there is no availability of local training within the NHS Boards, and if a Health Board / service area is starting or restarting a mindfulness service.
Start-up costs include costs of basic training, optional membership of BAMBA (this is not a requirement of mindfulness therapists in Scotland as there is use of an alternative listing procedure) and supervision fees. Additional costs apply including books / training materials / ongoing CPD events including mindfulness-based retreats / intensive training.
- Staff attendance at an 8-week mindfulness-based course (free if locally provided) or available at a number of locations (locally, on-line, staff-based course run by NES). Costs outwith NHS provision is typically £200 - £300 (may be less if delivered on-line).
- Therapist training course (free if locally provided) or available through a variety of training organisations (University, private or charity organisations), usually in the form of a 12-month programme of training at costs ranging from £1, 350 - £1, 500 from private organisations to £4000 to £5000 (University based). The courses differ in that some provide therapist training alone, some are competency assessed and others offer a Masters qualification.
- Supervision costs (free if offered locally with supervisors who have attended NES generic supervision training plus the “bolt on” training for mindfulness supervision) or privately at a variable cost (around £60 / hour). Expectation is for three half hour sessions of supervision (minimum for the delivery of a 8 week course) as a newly qualified therapist (over at least two 8 week courses) and ongoing monthly supervision (which can often be provided in a peer group setting).
- Fee for joining the BAMBA register of mindfulness therapists (optional for NHS Scotland therapists, but recommended if delivering privately), £90 for initial application and £37.50 for annual renewal.
- CPD costs (recommended two to seven days of annual training which may include CPD training days and intensive training in the form of practice “retreats”). £60 - £150 per day (costs vary). The NHS Scotland Mindfulness Network offers two CPD days per year (which are free to mindfulness therapists).
- Additional costs in the form of key texts / course books (around £25 - £100).
Building Staff Competency
Qualifications Required
MBSR is delivered in the NHS by professionals with a variety of backgrounds in health and social care (e.g., clinical psychology, psychiatry, occupational health, nursing, physiotherapy, OT, social work), who have training and experience in working with the population (in physical and/or mental health) to whom the intervention will be offered.
Personal interest in mindfulness / meditation practice and a willingness to develop and sustain a personal practice is vital, as the intervention is delivered from the in-depth experience and embodiment of the practice. Those who already have a personal mindfulness practice (including a mindful movement practice such as yoga, T’ai Chi) will probably have a shorter training journey as they already have an established practice.
Training Requirements
Training comprises a 1-2 year-long journey starting with the staff member attending an 8-week MBSR course as a participant and developing a stable, regular practice of mindfulness meditation / mindful movement. There are often opportunities for staff to take part in a patient-based course as a “staff participant” in their local health board areas. There is an expectation that personal practice is established for about one year prior to engaging in a therapist training course. Professionals who have a pre-existing and ongoing mindfulness practice might be particularly interested in training in mindfulness-based approaches and could proceed more quickly to the therapist training level. The therapist training component comprises up to 7 training days (but may be shorter in health board areas if the apprenticeship model can be applied). Training is often “generic” for the range of different mindfulness-based approaches or curriculums and will cover core features in common with MBSR and MBCT (Mindfulness Based Cognitive Therapy).
It is expected that trainees will deliver their first two courses under supervision / and as part of an apprenticeship model with a more experienced therapist prior to delivering courses independently.
There is no formal accreditation as part of the training courses, but local Mindfulness Leads (Scottish NHS Mindfulness Network)) in Health Board areas will approve trained staff as suitable for joining the NHS listing of therapists once they have completed training / apprenticeship and these will be listed on the NHS Mindfulness website.
Therapists may choose to join the UK based register of mindfulness teachers with the British Association for Mindfulness-Based Approaches (BAMBA) who use a formal registration and re-registration process for an annual fee. This is not a formal requirement for professionals who are trained to deliver mindfulness interventions in NHS Scotland. Ongoing mindfulness practice and CPD is a requirement for the delivery of MBSR.
Supervision Requirements
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in MBSR / mindfulness based approaches, the clinical area in which it is being delivered and has completed training in supervision of psychological therapies and interventions (further information: Supervision of psychological therapies and intervention | NHS Ed (scot.nhs.uk) including the Mindfulness specialist supervision training component.
One to one supervision is particularly helpful for newly qualified therapists and MBSR group supervision is useful (as an alternative to ongoing one to one supervision) for more experienced MBSR therapists.
Adults - Chronic Pain - Rating: 4
Supported - some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention.
Evidence - Rating: 4
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
Theory of Change
MBSR aims to increase mindfulness via enhanced present-moment awareness and nonreactivity. In anxiety conditions, enhanced levels of mindfulness are expected to reduce focus on past and future oriented ruminations and worry. It is also expected to increase decentering, translating to reductions in anxiety symptoms. In chronic pain conditions, increased mindfulness is expected to translate to increased pain acceptance, healthier responses to pain, and reduced pain associated distress.
Children and young people - Anxiety - Rating: 4
Children and Young People (CYP) MBSR Evidence for Anxiety
Some of the most relevant available evidence for MBSR for anxiety management in CYP include meta-analytic reviews and RCTs. These are described below.
The first meta-analytic study included 14 randomized controlled trials (RCTs) that evaluated the effectiveness of MBSR in adolescents and young people, aged 12-25 years, clinically diagnosed with anxiety (2).
The second meta-analytic study was conducted to determine the effectiveness of Mindfulness-Based Interventions (MBIs) on anxiety outcomes (3). The meta-analysis included 20 studies, involving 1582 participants aged 4-18 years. Seven studies included children and thirteen included adolescents. Outcomes for MBSR were not reported separately.
An RCT review (4) evaluated Universal delivery of a Mindfulness based intervention in 460 pupils in high school settings in the UK. People involved in these studies were not diagnosed with a mental health problem but were included as part of a whole classroom intervention which aimed to improve affective control and reduce future mental health problems.
CYP Anxiety Outcomes
Compared to inactive control groups who did not receive MBSR or MBIs (e.g., treatment as usual, waitlist control), the following outcomes were observed;
- Significantly reduced anxiety symptoms at post-treatment (3), and within 8-weeks post-treatment (2). Significant improvement in anxiety measures in the Odgers et al 2020 study was limited to children only studies.
- No evidence that the version of mindfulness training applied universally to a population of adolescents in school improved affective executive control (4) after benefits of mindfulness group interventions delivered to whole class groups are unlikely to be sustained (4).
Adults - GAD & Panic - Rating: 4
Adult MBSR Evidence for Anxiety
Some of the best available evidence for MBSR in the management of anxiety disorders include meta-analytic studies and RCTS. These are described below in date order, starting with the most recent.
The first is a meta-analytic study conducted to determine the effectiveness of acceptance and mindfulness-based approaches across DSM 5 anxiety disorders (5). Analysis included 23 studies, mostly of unclear risk of bias, included 1815 adults with different DSM-5 anxiety disorders. Eight of the included RCTs involved MBSR. Individual- and group-based approaches were included as well as online and offline/in-person settings. Control interventions included TAU/wait-list, individualized or group-based CBT, psychoeducation, and relaxation.
Another meta-analytic study was conducted to determine the effectiveness of psychological interventions in the treatment of anxiety, depression and stress in students (6). Analysis of anxiety interventions included 26 studies, involving 2602 students with ages that ranged between 6-53 years. The students were in university (17 studies), secondary (7 studies) and primary education (2 studies). Sub-group analysis based on intervention strategy was conducted, so mindfulness-based programmes were analysed as one group. Subgroup analysis based on the types of mindfulness interventions (e.g. MBSR or MBCT) was not conducted. Subgroup analysis based on the educational ages of the students for those that received mindfulness interventions was not conducted. The anxiety diagnostic instruments used in the included studies were mentioned, however, the review did not restrict eligibility criteria to include only studies with clinical populations.
The third was an RCT that was conducted to determine the effectiveness of MBSR on acute stress responses in adults (aged 18 years or over) diagnosed with GAD (7,8). The study included 93 adults who were randomised to receive either MBSR or an attention control class. MBSR was delivered as an 8-week group-based intervention, with a single weekend “retreat” day, and daily home practice guided by audio recordings. The study was conducted in USA.
The fourth was an RCT conducted to compare adapted MBSR to cognitive behavioural therapy (CBT) for the group treatment of anxiety disorders (9). The study included 105 Veterans, aged 18-75 years, with a principal (or dual principal) anxiety diagnosis (including PD/AG, GAD and SAD). Adapted MBSR was delivered over ten 90-minute group sessions, 3-hr retreat, and 20-30 minutes homework practice meditations. The study was conducted in USA.
The fifth was a meta-analytic study conducted to determine the effectiveness of mindfulness- and acceptance-based interventions for the treatment of anxiety disorders (10). The review included 19 studies with 491 participants with ages that ranged from 22 to 51 years. Participants had a primary diagnoses of anxiety disorders that included SAD in 7 studies, GAD in 4 studies, mixed anxiety disorders in 4 studies, anxiety and/ or comorbid depression in 3 studies, and panic disorder in 1 study. MBSR was evaluated in 4 studies and MBCT was evaluated in 8 studies. Separate comparative analysis for MBSR and MBCT was reported.
The sixth was an RCT that was conducted to determine the effectiveness of MBSR in patients with heterogeneous anxiety disorders (11). The study included 76 adults, aged 18-65 years, diagnosed with panic disorder with or without agoraphobia (PD/AG), social anxiety disorder (SAD), or generalized anxiety disorder (GAD). MBSR was delivered in eight weekly 2.5 h sessions, a half-day meditation retreat, daily home practice, and daily record keeping of mindfulness exercises. The study was conducted in Norway.
The seventh was a meta-analytic study conducted to determine the effectiveness of mindfulness-based intervention (MBIs) on anxiety and depression (12). The review included 39 studies consisting of 1,140 participants (aged 18-65 years) with diagnosable psychological or physical/medical disorders. The studies included those conducted in participants with generalized anxiety disorder (n=5), depression (n=4), and panic disorder (n=3). MBIs in this review included those that employed MBSR or MBCT, or were modelled on MBSR or MBCT. Meta-analysis for MBSR and MBCT studies were reported separately.
Adult Outcomes for Anxiety
Compared to control groups, the following outcomes were observed;
- Significantly reduced or significantly greater reduction in anxiety symptoms at post-treatment (6,8,10-12), sustained at 6-months follow-up (11,12).
- In comparison to Cognitive Behavioural Therapy (CBT), MBSR showed significantly lower effects on patient and clinician rated anxiety. Analyses up to 6 and 12 months did not reveal significant differences compared to TAU or CBT (5).
- Significantly reduced severity of principal anxiety disorder, sustained at 3-months follow-up for within group analysis (9).
- Significantly reduced depression measures at post-treatment and 6-months follow-up (11,12).
- Significantly greater reduction in stress markers post-treatment (7).
- Significantly greater increase in agreement with the positive statements (8).
Adults - Substance Use - Rating: 4
Adult MBSR Evidence for Substance Use
The available evidence for MBSR in substance use is more limited and is summarised in two meta-analytic reviews. These are described below, starting with the most recent.
A meta-analytic review of mindfulness based treatments for alcohol and substance use included 37 randomised and non-randomised trials (including 3531 patients) (18).
A meta-analytic review was conducted to determine the effectiveness of mindfulness-based interventions (including MBSR, Mindfulness-Based Relapse Prevention and Mindfulness-Oriented Recovery Enhancement) on substance use behaviours (19). The meta-analysis included 43 studies of which 34 were RCTs. Participants were aged at least 18 years and used mixed substances, alcohol or cigarettes.
Compared to inactive or active controls, the following outcomes were reported;
- Small effect sizes were detected in abstinence, levels of perceived stress, and avoidance coping strategies (18).
- Moderate effect sizes were revealed in anxiety and depressive symptoms (18).
- Large effect sizes were associated to levels of perceived craving, negative affectivity, and post-traumatic symptoms (18).
- Null effect sizes for attrition rate and overall mental health (18).
- significant small-to-large effects of mindfulness treatments in reducing the frequency and severity of substance misuse, intensity of craving for psychoactive substances, and severity of stress (19).
Adult - Chronic pain - Rating: 4
Adult MBSR Evidence for Chronic Pain
Some of the best available evidence for MBSR in chronic pain are summarised in meta-analytic reviews. These are described below, starting with the most recent.
A network meta-analysis was conducted to determine the comparative effectiveness of MBSR and CBT in patients with chronic pain (13). The review included 21 RCTs, with MBSR compared to controls in 7 (n=545) of the 21 RCTs. MBSR was delivered in standard format, i.e. 8 to 12 weekly sessions of approximately 2 to 2.5 hours each, a full-day intensive session, and daily home practice. Participants were aged 18 years or over, and presented with a minimum 3 months history of chronic pain (including fibromyalgia, rheumatoid arthritis, chronic lower back pain, failed back surgery syndrome, or pain of other aetiology).
A meta-analytic study conducted to evaluate the effectiveness of mindfulness-based interventions on chronic pain outcomes reviewed 11 RCTs of mindfulness-based interventions that followed the standard MBSR or MBCT formats (14). Participants were those presenting with chronic pain including those with fibromyalgia, chronic musculoskeletal pain, rheumatoid arthritis, failed back surgery syndrome, or pain of mixed aetiology. Chronic pain was defined as persisting for ≥13 weeks. The mean age of participants ranged from 47–52 years, with the exception of the two studies conducted in older adults with mean age of 75 years.
Another meta-analytic review was conducted to determine the effectiveness of acceptance commitment therapy (ACT) and mindfulness-based interventions for the treatment of chronic pain (15). The main analytic review included 25 RCTs, of which 16 RCTs were mindfulness-based (including MBSR or/ and MBCT). Most mindfulness-based interventions were delivered in standard format, however one study delivered MBSR as a self-help intervention. The 1285 participants in the main analysis were adults, with a mean age between 35 and 60 years. Participants presented with different types of pain including musculoskeletal pain, fibromyalgia, specific-site pain (e.g. chronic low back pain, chronic headache), and rheumatoid arthritis. Subgroup analysis reporting the effectiveness of mindfulness-based interventions were reported separately from ACT at post-treatment.
A fourth meta-analytic review was conducted to determine the effectiveness of mindfulness-based interventions (including MBCT and MBSR) on somatization disorders (16). The meta-analysis included 13 RCTs that involved participants aged at least 18 years, presenting with fibromyalgia, chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), or non-specified/ mixed somatization disorder. Subgroup analysis comparing the types of mindfulness-based interventions (i.e. MBSR, MBCT, or non-specified mindfulness-based therapy) evaluated the primary outcome only (i.e. symptom severity).
Adult Outcomes for Chronic Pain
Compared to inactive controls, the following outcomes were reported;
- Significantly reduced pain interference and pain intensity at post-intervention, sustained at 6-months follow-up
- Significantly improved physical functioning (13,14,16,17) and quality of life (14,16) at post-treatment. Effects on physical functioning sustained at 6-months follow-up (17).
- Significantly reduced depression symptoms at post-treatment (13,15-17), sustained at 6-months follow-up (17).
- Significantly reduced symptom severity (including fibromyalgia, IBS) at post-treatment for MBSR and across other mindfulness-based interventions (16).
- Significantly reduced pain outcomes (for IBS) at post-treatment (16).
- Significantly reduced sleep disturbance at post-treatment, sustained at 6 months follow-up (17).
Need
Comparable Population
MBSR is delivered to adults, adolescents and school-aged children to address a range of physical (chronic pain, diabetes, asthma) and psychological conditions (including depression and anxiety disorders). Evidence of effectiveness has been demonstrated in people (including Veterans) with panic disorder with or without agoraphobia (PD/AG), generalized anxiety disorder (GAD), and chronic pain.
Desired Outcome
MBSR is associated with significant improvement across several outcomes including anxiety, depression, physical functioning, and stress markers. Some effects have been observed at 3- and 6-months follow-up.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
MBSR focuses on training in mindfulness meditation techniques, with emphasis on coping with stress and promoting adaptive health behaviours. It aims to promote mindfulness via enhanced present-moment awareness and nonreactivity.
Priorities
MBSR aims to reduce focus on past and future oriented ruminations and worry, and to enable the acknowledgement and acceptance of objective present experiences without reacting to negative experiences. It can be delivered to adults, adolescents and school-aged children to address a range of physical (chronic pain, diabetes, asthma) and psychological conditions (including depression and anxiety disorders).
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
MBSR can be delivered by professionals with backgrounds in health (physical and/ or mental) and social care. Practitioners are required to attend an 8-week MBSR course, a 12-month MBSR therapist training course, and teach two supervised 8-week MBSR courses. MBSR is delivered over 8 weekly in-class sessions, each lasting about 2 hours, or can be delivered as an on-line course.
Technology Support
Practitioner teacher training and supervision can be accessed remotely. MBSR can be delivered as an online course.
Administrative Support
MBSR is delivered over 8 weekly sessions in a number of settings (e.g. prisons, schools, community settings, and corporate environments). MBSR can also include a one-day meditation retreat. Administrative support will be needed for organising the course.
Financial Support
In Scotland, training is overseen by the Scottish NHS Mindfulness Network supported by NHS Education for Scotland. Therapist training and supervision can often be run within health boards by experienced trainers. The only cost for this is allocating time for trainee therapists and supervisor / trainer(s). However, this training route currently has a limited capacity.
External training is also available. The Mindfulness-Based Stress Reduction (MBSR) course costs around £200 for the 8-week course (may be less if delivered online). The 12 month therapist training course costs around £1,500 per practitioner (if delivered by a private organisation or up to £4, 000 - £5,000 (if delivered by a University). Additional costs for MBSR resources and activities should be considered.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
