- Title
- Treatment fidelity in complex health behaviour change research: an in-depth examination of real-world evaluations of behaviour change counselling
- Creator
- Beck, Alison Kate
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2022
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Background: Behaviour change counselling (BCC) is an adaptation of motivational interviewing (MI) designed to maximise the effectiveness of time-limited health behaviour change consultations. To improve intervention quality, and understanding of treatment effects, it is recommended that evaluations of health behaviour change interventions incorporate existing fidelity frameworks (e.g. The National Institutes of Health (NIH) Behaviour Change Consortium) and ensure that treatment fidelity is assessed and reported. Ensuring that promising interventions can be delivered adequately (i.e. with fidelity) by clinicians within real-world settings is an essential step in developing interventions that are both effective and ‘implementable’. However, evidence from real-world evaluations of BCC is lacking. Aims and Objectives: This PhD is designed to examine treatment fidelity within evaluations of BCC delivered by existing providers within real-world healthcare settings. Specifically, to: 1. Ensure that published fidelity recommendations are incorporated into a stepped-wedge, randomised clinical trial of “EAT: Eating as Treatment”, a novel dietitian-delivered BCC intervention 2. Examine adherence to NIH fidelity recommendations within BCC evaluations 3. Explore the relationship between treatment fidelity and patient outcomes. Methods: An experimental investigation of fidelity was conducted as part of the EAT clinical trial. As trial co-ordinator for the EAT Trial, I instigated this experimental evaluation by a) integrating published fidelity recommendations into the conduct of the trial and b) conducting a pilot study to inform training and fidelity methods. I subsequently commenced a PhD and concluded the evaluation by a) examining adherence, competence and differentiation and b) exploring the relationship between provider fidelity and patient outcome. A systematic review and meta-analysis was then conducted to examine adherence to NIH fidelity recommendations within the literature, provider fidelity to BCC and the relationship of these variables to the effectiveness of BCC for adult health behaviours or outcomes. Findings: The pilot study provided preliminary evidence that dietitian use of BCC significantly improved after training. In the EAT clinical trial, motivational and behavioural strategies (but not routine elements of care, therapeutic alliance or dose) were greater in post-training consultations. An inverse relationship was detected between provider fidelity and the nutritional status of intervention patients. In the systematic review (n=58), study adherence to NIH fidelity recommendations varied widely, and meta-regressions revealed a complex relationship between study adherence to NIH recommendations and intervention effect size. Inadequate reporting of fidelity outcomes in the included studies precluded the proposed meta-regression between fidelity to BCC and intervention effect size. Importance and implications: This thesis represents the first comprehensive evaluation of treatment fidelity within BCC, an important real-world therapeutic approach. We addressed a long-standing limitation in the complex behaviour change literature by comprehensively considering, evaluating and reporting fidelity in our evaluation of EAT. We provide robust evidence for short-term (pilot) and sustained (clinical trial) change in provider delivery of BCC under real-world conditions. Our findings attest to the clinical benefits of EAT, and suggest that provider fidelity is influenced by patient behaviour and may be greater when patients are struggling to change. This thesis also provides the first evidence for the clinical impact of adopting NIH fidelity recommendations, and lends new insight into the real-world effectiveness of BCC. Transparent consideration, evaluation and reporting of fidelity remain important priorities for future research. Understanding the interplay between patient and provider characteristics, intervention elements and the various components of fidelity is essential. Only then can the relationship between fidelity and treatment outcome be clarified, thereby allowing BCC training, delivery and evaluation to be tailored for maximum effect.
- Subject
- fidelity; behavior change counselling; motivational interviewing; complex behaviour change research; NIH fidelity gudelines
- Identifier
- http://hdl.handle.net/1959.13/1513703
- Identifier
- uon:56761
- Rights
- Copyright 2022 Alison Kate Beck
- Language
- eng
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