INTERVENTION MANUAL
9.1 CONCEPTUALIZATION OF FIDELITY
9.1.3 Definition of Fidelity
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their operationalization into specific components. This consistency is foundational for ensuring construct validity of interventions. Accordingly, the first and third definitions are relevant for a comprehensive conceptualization of fidelity. The con- ceptualization posits two levels of fidelity:
1. Theoretical fidelity: As originally proposed by Bellg et al. (2004), theoretical fidelity has to do with the design of the intervention. It refers to the consis- tency between the intervention’s active ingredients as specified in the inter- vention theory and the intervention’s components as described in the logic model, protocol, or manual. In other words, the content, activities and treatment recommendations comprising the intervention components are congruent, in alignment, and accurately reflective of the active ingredients (Haynes et al., 2016; Keller et al., 2009).
TABLE 9.1 Recently mentioned frameworks of intervention fidelity.
Framework Source Definition and domains of fidelity
Consolidated Framework
for Implementation Fidelity Carroll et al. (2007) Definition:
Fidelity is the degree to which interventions are implemented or delivered as intended
Domain:
Fidelity is operationalized in adherence to the intervention protocol or manual
Moderating factors:
Complexity of intervention, quality of delivery, facilitation strategies, client responsiveness Treatment Fidelity
Framework Originally published by Bellg
et al. (2004) on behalf of the National Institutes of Health—Behavioral Change Consortium
Definition:
Fidelity encompasses methodological strategies used to monitor and enhance the reliability and validity of interventions
Domains:
Design (or fidelity to theory), training, delivery or implementation, receipt, enactment
National Implementation
Research Network Domains:
Context, content, competence (covering interventionists’ decision making), client responsiveness
Comprehensive Intervention
Fidelity Guide Gearing et al. (2011) Domains:
Design, training, monitoring of intervention fidelity, intervention receipt
Fidelity of Technology-Based
Interventions DeVito Dabbs et al. (2011) Domains:
Delivery, receipt, technology acceptance Adapted Model of Fidelity Wainer and Ingersoll (2013) Domains:
Delivery (i.e. adherence, exposure, differentiation)
Moderating factors:
Complexity of intervention, facilitation strategies, competency, comprehension, social validity Treatment Implementation
Model Lichstein et al. (1994) Domains:
Delivery, receipt, enactment
2. Operational fidelity: Operational fidelity has to do with the delivery of the intervention. It refers to the extent to which the intervention, represented in its components, is delivered as originally designed or planned. As such, oper- ational fidelity reflects the degree to which the interventionists adhere to the intervention manual (Aggarwal et al., 2014; Berkel et al., 2019; Forsberg et al., 2015).
Most frameworks (Table 9.1) were primarily concerned with operational fidelity and extended it to cover domains representing the implementation of interventions by the interventionists and the clients. The extension is based on the realization that the implementation of health interventions is the responsibility of both. Interven- tionists are ascribed the functions of relaying content to and engaging clients in the activities as planned; whereas clients exposed to the intervention are expected to engage and enact treatment in daily life. Accordingly, in the frameworks, operational fidelity is represented in the following domains: adherence, competence and differentiation for interventionists, and responsiveness, exposure, receipt or engage- ment, and enactment for clients. Each of these domains is defined next.
9.1.3.1 Domains of Fidelity—Interventionist Adherence
Adherence to the intervention is the core of fidelity. It refers to whether or not the intervention is delivered as designed or intended (Wainer & Ingersoll, 2013). Adher- ence implies that the interventionist performs the prescribed activities or behaviors for providing the treatment, as described in the intervention manual (Forsberg et al., 2015; Wojewodka et al., 2017) and avoids proscribed activities or behaviors.
Prescribed activities are those reflecting the intervention’s active ingredients, repre- sented in the specific components. Proscribed activities include those comprising TABLE 9.2 Conceptual definitions of intervention fidelity.
Definition Source
1. Degree or extent to which an intervention is actually delivered or implemented as designed or planned or intended
Aggarwal et al. (2014), Berkel et al. (2019), Breitenstein et al.
(2010), Brandt et al. (2004), Campbell et al. (2013), Carroll et al. (2007), Carpinteiro da Silva et al. (2014), DeVito Dabbs et al. (2011), DiRezze et al. (2013), Dunst et al. (2013), Forsberg et al. (2015), French et al. (2015), Hasson (2010), Haynes et al.
(2016), Ibrahim and Sidani (2016), Judge Santacrocce et al.
(2004); Lorencatto et al. (2014), Mowbray et al. (2003), Prowse and Nagel (2015), Oxman et al. (2006), Roy et al. (2018), Schulte et al. (2009), Seys et al. (2019), Southam-Gerow and McLeod (2013), Toomey et al. (2019), Wojewodka et al. (2017) 2. Methodological (quantitative and qualitative)
strategies used to monitor and enhance the reliability and validity of interventions; that is, processes that ensure interventions are consistently implemented as outlined in the protocol
Bellg et al. (2004), Borrelli et al. (2005), Hart (2009), Mars et al. (2013), Resnick et al. (2005), Stein et al. (2007), Swindle et al. (2018)
3. Consistency with the components of the
intervention theory Keller et al. (2009), Pearson et al. (2005) 4. Quality of implementation Forsberg et al. (2015), Saunders et al. (2005)
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other treatments such as the use of cognitive reframing in a purely behavioral inter- vention and general activities that detract from the treatment such as allowing the focus of a treatment session to shift to irrelevant topics (Campbell et al., 2013; DiRezze et al., 2013; Stein et al., 2007). Adherence represents the quantity of intervention delivery (Berkel et al., 2019). It is quantified as the number of the intervention’s com- ponents that are actually provided or the number of prescribed activities actually performed, out of those planned.
Adherence is enhanced by: 1) having an intervention manual that specifies the activities to be performed and how, and the activities to be avoided; 2) training inter- ventionists in the theory and skills for providing the intervention; and 3) requesting interventionists to follow the intervention manual when delivering the intervention.
Competence
Competence (also called process fidelity by Dumas et al., 2001) focuses on the manner in which the interventionists deliver the intervention. Competence relates to the interventionists’ skillfulness at providing the intervention (Leeuw et al., 2009;
Stein et al., 2007). A range of skills have been mentioned in the literature as reflecting interventionists’ competence. The most common skills pertain to: delivering the intervention while responding appropriately to client characteristics, concerns, and life circumstances (Hartley et al., 2014; Mars et al., 2013; Carpinteiro da Silva et al., 2014); engaging in nonspecific behaviors such as being flexible; adapting the content or activities to clients’ concerns and circumstances (Campbell et al., 2013);
being client-centered (Aggarwal et al., 2014); showing empathy (Aggarwal et al., 2014); communicating information clearly, at an appropriate pace and in an engaging or interactive way (Wojewodka et al., 2017); demonstrating understanding of clients’ life situation; clarifying information; providing constructive feedback;
and collaborating with clients (Berkel et al., 2019; Carpinteiro da Silva et al., 2014;
Hartley et al., 2014).
The interventionists’ competence skills have been characterized slightly differ- ently. Roth and Pilling (2008) identified them as generic skills and defined them as those exhibited in working collaboratively with clients. Dixon and Johnston (2010) characterized the skills as foundation competencies; these skills involve generic com- munication skills, ability to engage and collaborate with clients, and capacity to adapt treatment in response to clients’ concerns and feedback. Alternatively, these skills encompass communication, interactional style, and development and maintenance of a therapeutic relationship or working alliance, as described in Chapter 8.
In general, competence entails generic (also called common factors) therapeutic skills of interventionists and accounts for the interventionist effects on client out- comes. Competence has been characterized as the quality of intervention delivery (Berkel et al., 2019; Southam-Gerow & McLeod, 2013). It is enhanced with careful selection of interventionist and provision of constructive feedback on these generic skills.
Differentiation
Differentiation is the domain of fidelity concerned with the distinctiveness of the health intervention and other treatments provided to clients in an evaluation study or in practice. It refers to the extent to which the treatments differ from one another in the intended ways (Hasson, 2010; Wainer & Ingersoll, 2013). This means that the interventionists perform the activities prescribed for each treatment and avoid the
proscribed ones (Aggarwal et al., 2014; Forsberg et al., 2015), thereby avoiding contamination of the treatments.
9.1.3.2 Domains of Fidelity—Client Responsiveness
Client responsiveness has not been lucidly defined at the conceptual level. At the operational level, client responsiveness encompasses domains of fidelity that pertain to clients’ implementation of the intervention. It reflects clients’ exposure to, engage- ment in, and enactment of the intervention.
Exposure
Exposure represents the amount of the intervention to which clients are exposed. In other words, exposure is the dose of the intervention that clients actually receive (Hasson, 2010; Ibrahim & Sidani, 2016; Wainer & Ingersoll, 2013), reflecting the level of contact with the intervention content. It is usually quantified as attendance at the intervention sessions or self-completion of the intervention modules.
Receipt or Engagement
Both terms are often used interchangeably to denote clients’ active involvement in the planned intervention activities, comprehension of the content presented in the intervention sessions or modules, and capacity to employ the skills or perform the behaviors required for applying the treatment recommendations (Leeuw et al., 2009;
Wainer & Ingersoll, 2013). Clients’ involvement in the intervention activities, such as participation in discussion of the treatment recommendations and reading accompa- nying materials, helps them to gain a good understanding the intervention and to retain the information. The acquired knowledge promotes their confidence to imple- ment the skills, behaviors, or treatment recommendations in daily life (Prowse &
Nagel, 2015; Walton et al., 2017). The results of two literature reviews on fidelity indi- cated that receipt or engagement is operationalized into: understanding or knowledge of the intervention content, self-efficacy, and acceptability or satisfaction with the intervention (O’Shea et al., 2016; Rixon et al., 2016).
Enactment
Enactment is defined as the degree to which clients actually apply the treatment rec- ommendations in their daily life during (i.e. in-between intervention sessions) and following the treatment period (Ibrahim & Sidani, 2016; Prowse &, Nagel 2015;
Wainer & Ingersoll, 2013). As defined, enactment has traditionally been discussed under the rubric of client adherence to treatment.