Major ingredients of fidelity: A review and scientific guide to improving quality of intervention research implementation

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Abstract

Despite the critical role of fidelity and the proliferation of intervention manuals and related measures, no comprehensive, structured guide exists, resulting in definitional confusion, varying interpretations of what constitutes core components, and inconsistent application of methods to ensure fidelity. To improve integration of fidelity criteria into intervention research, this review paper focuses on three aims: 1) to identify, define, and operationalize the key ingredients and components of intervention fidelity; 2) to identify consistency and uniformity in terms of core characteristics of fidelity; and, 3) to provide a comprehensive fidelity tool that assesses the core ingredients of fidelity that can be used by researchers to measure the degree of fidelity. Twenty-four (n = 24) meta-analyses and review articles focusing on fidelity were identified in a systematic literature search over the past 30 years. A comprehensive review and fidelity guide outlining four required components of intervention research (design, training, monitoring of intervention delivery, and intervention receipt) was developed, with special consideration given to threats and measurement. Fidelity is imperative in all stages and phases of intervention research. This review and guide can be used by practitioners and researchers in their scientific process of designing and implementing community-based psychological, social, and behavioral intervention research.

Research Highlights

►Definitional inconsistency and varying conceptual interpretations undermine fidelity. ►Fidelity is necessary for accurate interpretations of treatment effects. ►All stages/phases of intervention research, design, and implementation require fidelity. ►This review presents a comprehensive scientific guide that measures fidelity.

Introduction

In the last three decades there has been an increasing emphasis on the importance of the use of fidelity assessment on improving the science of psychological, social, and behavioral research. Intervention fidelity refers to the extent to which core components of interventions are delivered as intended by the protocols (Bond et al., 2000, Dusenbury et al., 2003, McIntyre et al., 2007, Yeaton and Sechrest, 1981). Fidelity is necessary for accurate interpretations of treatment effects (Perepletchikova & Kazdin, 2005). Although fidelity has increasingly assumed an essential role in intervention research, as evidenced by the proliferation of intervention manuals and related measures, the lack of a comprehensive, structured guide has produced definitional ambiguity and confusion. Definitional inconsistency and varying conceptual interpretations undermine what constitutes core components of fidelity and foster inconsistent application of methods.

Fidelity emerged in the research literature in the 1980s. Yeaton and Sechrest (1981) identified three dimensions of treatment fidelity when choosing a treatment plan for psychological intervention: strength, integrity, and effectiveness of treatment. Later, Waltz, Addis, Koerner, and Jacobson (1993) added greater emphasis on the use of treatment manuals as a means to improve the purity of interventions and provide clinicians treatment protocols, as well as parsing treatment integrity into therapist adherence and therapist competence. Borelli et al. (2005) further developed fidelity to include guidelines and recommendations for design, training, delivery, receipt, and enactment of the treatment intervention.

This review builds from the work of these authors and others to provide a comprehensive scientific-based guide to the essential core components of intervention fidelity ingredients and assessment. To improve integration of fidelity criteria into intervention research, this paper focuses on three aims: 1) to identify, define, and operationalize the key ingredients and components of intervention fidelity; 2) to identify consistency and uniformity in terms of core characteristics of fidelity; and, 3) to provide a comprehensive fidelity tool that assesses the core ingredients of fidelity that can be used by researchers to measure the degree of fidelity. Establishing a uniform measure of fidelity will allow clinicians to choose and utilize psychosocial, social, and behavioral interventions that show scientific evidence that changes during treatment are due to the specific components of that intervention.

Section snippets

Methods

Peer-reviewed articles were searched over a thirty year period between January 1, 1980 and December 31, 2009, using the PsycInfo, Medline, and Social Services Abstracts databases for the terms “fidelity,” “adherence,” and “integrity.” Searches were limited to peer-reviewed literature reviews, systemic reviews, and meta-analytic review articles. Articles were excluded when: 1) fidelity was not a primary focus; 2) the focus was exclusively on intervention-specific measurement tools; and 3) the

Findings

The review identified four core components of intervention fidelity: 1) intervention design and protocols; 2) intervention training; 3) monitoring of intervention delivery; and, 4) monitoring of intervention receipt. In order to develop a unified structure through which fidelity can be assessed, each of the four components was divided into the subcategories of protocols, execution, maintenance, feedback, and threats. Protocols encompass the framework, standards, and essential components guiding

Elements of fidelity

Design is the first core component of fidelity. The framework of an intervention is comprised of elements essential to the design of a trial as well as elements needed to evaluate or replicate the study (Borelli et al., 2005). A program model is a well-defined set of interventions and procedures to help individuals achieve the desired goal (Bond et al., 2000). Population specifics are cultural, social, and personal characteristics of the target population (Bauman et al., 1991, Dane and

Discussion

This review indicates that a lack of uniformity exists in the construct and definition of fidelity. Authors frequently use different terms to refer to the same concept or construct. In an attempt to address this, each component, subcategory and element was clearly developed, agreed upon, and then defined. Moreover, a lack of uniformity also persists in the implementation and weighting of essential elements across the four core components that comprise fidelity. Greater attention needs to be

Implications for clinicians

This review has several implications for the clinical dissemination of research-based programs to interventionists and agencies. Accurately assessing fidelity during the implementation of manual-based interventions is particularly important in determining intervention outcomes. Failure to implement an intervention with a high degree of fidelity could undermine evidence-based practice and negatively affect the accuracy of clinical case evaluations.

A number of clinical considerations for agencies

Implications for researchers

Fidelity warrants systematic consideration and application across all types of research design (naturalistic, pre–post, quasi-experimental, and RCTs). Fidelity should also be implemented in all stages of research. Fidelity is usually emphasized in the developmental and piloting stage of research (Stage 1) (Rounsaville, Carroll, & Onken, 2001), but it is also essential in RCTs (Stage II) and in studies of dissemination and transportability (Stages III and IV). Fidelity requires researchers to

Future research

Increased awareness and attention to the core components of fidelity will not only inform researchers, interventionists, and organizations of their importance (Tucker & Blythe, 2008), but will also enhance effective implementation of psychosocial interventions as well. Future attention may be further supported through increased focus of fidelity in journals and scientific conferences (Perepletchikova et al., 2007). Researchers have called on journals to include fidelity and encourage the

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