Treatment fidelity

Occupational therapy interventions are difficult to evaluate because they are complex and dependent on therapist and client interactions. Psychotherapy and health behavior change interventions are similar in this respect, but to improve credibility for evidence-based interventions, over the previous few decades these fields have made significant progress in requiring that outcomes research incorporate and report treatment fidelity methods. Treatment fidelity is simply the degree to which an intervention was delivered as designed. However, health behavior change research has identified multiple components of treatment fidelity in outcomes research (Bellg et al., 2004). Leaders in these fields have urged researchers to measure and report the following components for achieving treatment fidelity: define specific characteristics or active ingredients of the intervention so that it is replicable (treatment design); provide standardized training of the clinicians to ensure the accuracy and consistency of delivery of the intervention over time (treatment integrity); ensure that the experimental and control treatment conditions are distinct from one another (treatment differentiation); assess how well the subjects understand the treatment (treatment receipt); and determine if the subjects apply the intervention (treatment enactment). These concepts and techniques can be incorporated into occupational therapy research and, as in psychotherapy and behavior change interventions, can lead to increased confidence that the outcomes of a study are attributable to the active ingredients of the intervention and not to extraneous variables or differences in practitioners who deliver the intervention (Bellg et al., 2004).

Rehabilitation researchers have developed methods to address treatment fidelity. Parham et al. (2007) examined fidelity of sensory integration (SI) studies to underlying SI principles. They concluded that SI treatment fidelity was poor, thus compromising the conclusions that can be drawn as to its effectiveness, and the authors went on to develop a fidelity tool to evaluate adherence of interventions to SI principles (Parham et al., 2011).

Hildebrand et al. (2012) described the development of training and supervision measures and techniques to enhance the adherence and competence of therapists’ delivery of a unique rehabilitation intervention for older adults and the measurement of treatment differentiation between the experimental and standard-of-care groups. They reported that the success in using these methods for treatment integrity and differentiation provided greater confidence in the outcomes of their research.

Treatment fidelity measures are available for occupational therapy researchers to utilize in their own research. Hand et al. (2018) performed a systematic review to find fidelity measures of occupational or physical therapy interventions. They found eight fidelity measures of such interventions as community integration, SI, and motivational interviewing. The eight fidelity measures evaluated treatment integrity and treatment differentiation most commonly. In this issue, Bowyer and Tkach (2018) provide further introduction to treatment fidelity concepts and review Model of Human Occupation (MOHO) research for its use and reporting of the five treatment fidelity components. They measured treatment fidelity of MOHO research using the Treatment Fidelity Checklist, a tool that was developed for researchers and consumers of research to evaluate the treatment fidelity of their own and others’ research (Borrelli et al., 2005). They found that treatment design and enactment were well depicted, but treatment integrity was poorly described.

For practitioners, Breckenridge and Jones (2015) made the argument that occupational therapists must examine their own treatment fidelity in practice, although they feared that rigid adherence to a treatment protocol might compromise the client-centered values at the core of our profession. As a practitioner, when reading the results of outcomes research, please consider the following questions. Did the researchers create an intervention protocol and provide training to practitioners? How did researchers ensure that the practitioners delivered the experimental treatment as intended throughout the trial? Did the subjects of the intervention receive and understand the treatment and did they enact it?

For occupational therapy researchers, treatment fidelity planning and monitoring should be an integral part of the design and implementation of any outcomes research. This may involve more time and work in the initial phases, but efforts will be rewarded with the identification of effective occupational therapy interventions and greater credibility attributed to them.

Both researchers and practitioners must evaluate the five components of treatment fidelity to improve the quality and outcomes of research and of occupational therapy treatment.