Abstract / Summary
Abstract Background Evidence-based post-diagnostic dementia support is not equitably available in routine care. GRACE (Goal-diRected ACcessible, Equitable, evidence-based Care) is a manualised, goal-focused programme for people living with dementia and family carers (GRACE-family), developed with a complementary workforce intervention for home care staff (GRACE-professional). GRACE has demonstrated clinical and cost-effectiveness in trial settings, providing a strong foundation for wider implementation. We aimed to co-adapt GRACE to optimise its inclusivity and fit with diverse populations and service contexts, and to systematically report both the resulting adaptations and the co-adaptation process itself. Methods Between 2025 and 2026, a co-adaptation group comprising people with lived, professional and academic experience integrated work from eleven co-adaptation workshops with 19 people with lived experience of dementia and 38 with professional and/or academic experience. Observational field notes, workshop notes, participant interview transcripts and successive intervention manual drafts were analysed. We used deductive thematic analysis to characterise the co-adaptation process and documented modifications using the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions (FRAME) to document modifications. Results Two themes characterised the adaptation process: designing for all intended beneficiaries , by strengthening the voice of people living with dementia and improving cultural, linguistic and disability accessibility; and balancing flexibility with fidelity , by adapting content, session structure and delivery while preserving the intervention’s core functions. Adaptations included a new module on care-home transitions and a tailored introductory session for people diagnosed in hospital; improved accessibility for people with learning disabilities and people with low literacy; modifications to enable peer delivery of GRACE-professional by home-care workers; and linguistic and cultural changes for delivery in Urdu and Hindi. The co-adaptation process involved sustained collaborative problem-solving but also highlighted tensions around the assumptions underpinning the dyadic intervention model and the limits of adapting an existing intervention. Conclusions This study highlights co-adaptation as an equity-oriented implementation strategy and demonstrates the value of combining structured adaptation reporting with participatory methods. GRACE is now ready for implementation and evaluation in routine dementia care to assess whether these modifications improve the equitable reach, uptake and experience of post-diagnostic support.