Advances in fidelity measurement for mental health services research

Abstract

OBJECTIVE: Mental health intervention research requires clear and accurate specification of treatment conditions in intervention studies. Measures are increasingly available for community-based interventions for persons with serious mental illnesses. Measures must go beyond structural features to assess critical processes in interventions. They must also balance effectiveness, adequate coverage of active treatment elements, with efficiency, the degree to which measures may be used cost-effectively. The context of their use is changing with the emergence of new frameworks for implementation research and quality improvement. METHODS: The focus, content, and results of preliminary studies of four recently developed fidelity measures are described. Measures respectively assess fidelity to case management, cognitive therapy for psychosis, illness management and recovery, and assertive community treatment. RESULTS: Fidelity measures described assess interventions in a range of treatment contexts from dyads to teams. Each measure focuses assessment resources on the elements critical to the respective intervention. Each has demonstrated coverage of its target intervention and satisfactory psychometric properties and is related to outcomes. Measures have been used for training, quality improvement, or certification. Current fidelity measures assess domains and have uses beyond their nominal position in implementation and quality frameworks. CONCLUSION: Process components in community-based interventions can be effectively assessed in fidelity measures. Omission of elements assessing potentially critical, active treatment components poses risk to both research and practice until there is evidence to demonstrate they are non-essential. Further development of fidelity measurement theory and approaches should articulate with development of theory and methods in implementation science.