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Assessment of treatment fidelity considered in relation to mindfulness based cognitive therapy and Aboriginal Torres Strait Islander mental health initiative motivational care planning.
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posted on 24.02.2017by Prowse, Phuong-Tu Doan
In clinical trials of psychological treatments, attaining adequate Treatment Fidelity (TF) is important for efficacy and effectiveness assessment. Inclusion of TF tools in empirical studies can assist hypothesis-testing, enhance internal and external validity, and encourage study replication. Measuring TF assists program evaluators in attributing the absence of desired results in a service setting to program design deficiencies, poor implementation, or a combination of both. In many ways then, measurement of TF contributes to the development of evidence relevant to clinicians, managers and healthcare commissioners. The aims of this research are to firstly systematically to evaluate the role and utility of TF within evidence based psychological therapies, then to explore and extend the fidelity approaches contained in two interventions: Mindfulness Based Cognitive Therapy (MBCT) and Motivational Care Planning (MCP). MBCT is an intensive eight-week program aimed at preventing relapse and recurrence of Major Depressive Disorder. MCP is a culturally adapted brief intervention designed for Indigenous Australians experiencing mental health issues including depression in community settings. Systematic review and meta-evaluation examined TF research from the last decade. A mixed methods approach examined the role of TF in delivery of MBCT and MCP. This work informed development of an abbreviated self-assessment TF tool for MBCT, suggested as a measure practical for routine clinical use. Meta-evaluation identified differences in TF Models and disparities in researcher investment in TF methods. Systematic review found that although studies with embedded fidelity tools attained higher TF levels, there was overall low usage of fidelity measures. It is suggested that this inconsistency may in part be attributable to the lack of specific recommendations within widely used clinical-trial guidelines. An existing MBCT Adherence Scale (the MBCT-AS) proved valuable in assessing MBCT treatment fidelity while the newly developed MCP-Adherence Scale showed promise in terms of strengthening MCT fidelity. Self-assessment scales can provide a portable and cost effective fidelity tool to support clinicians’ daily practice and the newly developed MBCTSelf Assessment Scale (MBCT-SAS) offers another method to reinforce the MBCT fidelity framework and promote program quality assurance. The body of work in this thesis affirms that integration of TF measures supports quality research outcomes. Inclusion of fidelity tools is linked to higher TF levels during program implementation. The quality of clinical trials would be enhanced through integration of multi-method TF strategies within existing Guidelines. The establishment of a suite of robust TF tools would better equip clinicians to practice with high levels of fidelity. The MBCT and MCP adherence scales strengthen the TF frameworks of those programs. The development of the MBCT-SAS can contribute to strengthening TF assessment in MBCT delivery. Suggestions for further research include: generally working better to link psychological TF with research and clinical outcomes; specifically further validation work on the MCP-AS and MBCT-SAS could strengthen their basis for consideration in translational research and clinical practice. A case is suggested for revision of current clinical trials guidelines to promote consistency of TF measurement in future research.