Denise Ernst

Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium.

Treatment fidelity refers to the methodological strategies used to monitor and enhance the reliability and validity of behavioral interventions. This article describes a multisite effort by the Treatment Fidelity Workgroup of the National Institutes of Health Behavior Change Consortium (BCC) to identify treatment fidelity concepts and strategies in health behavior intervention research. The work group reviewed treatment fidelity practices in the research literature, identified techniques used within the BCC, and developed recommendations for incorporating these practices more consistently. The recommendations cover study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills. Funding agencies, reviewers, and journal editors are encouraged to make treatment fidelity a standard part of the conduct and evaluation of health behavior intervention research.

A New Tool to Assess Treatment Fidelity and Evaluation of Treatment Fidelity across 10 Years of Health Behavior Research.

A. Bellg, B. Borrelli, et al. (2004) previously developed a framework that consisted of strategies to enhance treatment fidelity of health behavior interventions. The present study used this framework to (a) develop a measure of treatment fidelity and (b) use the measure to evaluate treatment fidelity in articles published in 5 journals over 10 years. Three hundred forty-two articles met inclusion criteria; 22% reported strategies to maintain provider skills, 27% reported checking adherence to protocol, 35% reported using a treatment manual, 54% reported using none of these strategies, and 12% reported using all 3 strategies. The mean proportion adherence to treatment fidelity strategies was .55; 15.5% of articles achieved greater than or equal to .80. This tool may be useful for researchers, grant reviewers, and editors planning and evaluating trials.

Motivational interviewing in health promotion: it sounds like something is changing.

Motivational interviewing (MI), initially developed for addiction counseling, has increasingly been applied in public health, medical, and health promotion settings. This article provides an overview of MI, outlining its philosophic orientation and essential strategies. Major outcome studies are reviewed, nuances associated with the use of MI in health promotion and chronic disease prevention are described, and future directions are offered.

Social networks as predictors of ischemic heart disease, cancer, stroke and hypertension: Incidence, survival and mortality

Three social network measures were obtained from a randomly sampled cohort of 2603 HMO members in 1970-71. Mortality and first incidence of ischemic heart disease, cancer, stroke, and hypertension were assessed over the next 15 years. Outcome data were adjusted for age, sex, smoking, SES, and baseline health status. Persons with histories of a given morbidity at or prior to baseline were excluded from the analyses of that morbidity. Social network measures, particularly network scope (a measure of the number of different domains in which a person has social contacts), were powerful predictors of 15-year mortality hazard, but weak predictors of incident disease. Only network scope predicted IHD incidence, and none of the other morbidities was predicted by the social network measures. However, social network measures were strong predictors of both cause-specific and all-cause mortality among persons who had incident cases of IHD, cancer, and stroke. These data suggest that social networks may be more effective in supporting recovery after illness has occurred than in preventing the incidence of new disease.

The Motivational Interviewing Treatment Integrity Code (MITI 4): Rationale, Preliminary Reliability and Validity

UNLABELLED The Motivational Interviewing Treatment Integrity code has been revised to address new evidence-based elements of motivational interviewing (MI). This new version (MITI 4) includes new global ratings to assess clinicians attention to client language, increased rigor in assessing autonomy support and client choice, and items to evaluate the use of persuasion when giving information and advice. METHOD Four undergraduate, non-professional raters were trained in the MITI and used it to review 50 audiotapes of clinicians conducting MI in actual treatments sessions. Both kappa and intraclass correlation indices were calculated for all coders, for the best rater pair and for a 20% randomly selected sample from the best rater pair. RESULTS Reliability across raters, with the exception of Emphasize Autonomy and % Complex Reflections, were in the good to excellent range. Reliability estimates decrease when smaller samples are used and when fewer raters contribute. CONCLUSION The advantages and drawbacks of this revision are discussed including implications for research and clinical applications. The MITI 4.0 represents a reliable method for assessing the integrity of MI including both the technical and relational components of the method.

An intervention for treating alcohol dependence: relating elements of Medical Management to patient outcomes with implications for primary care.

PURPOSE Alcohol dependence, frequently seen in medical settings, is a major problem that affects the health and well-being of many individuals and their families. The purpose of this study was to examine the relationship between treatment outcomes and patient and clinician factors specifically associated with a medically oriented intervention given for the treatment of alcohol dependence. The intervention was developed for the National Institute on Alcohol Abuse and Alcoholism–sponsored COMBINE Study, a randomized controlled trial combining 2 medications, naltrexone and acamprosate, with Medical Management, with or without specialty alcohol treatment. METHODS We examined the effect of patient adherence to treatment (number of Medical Management visits, total minutes in treatment, alliance or therapeutic relationship with the clinician, patient satisfaction with treatment, and clinician adherence to the Medical Management protocol) on abstinence from alcohol, amount of heavy drinking, and clinical improvement during treatment. RESULTS More Medical Management visits attended and less total time spent in Medical Management treatment was associated with more days of abstinence from alcohol, reductions in heavy alcohol drinking, and a higher likelihood of clinical improvement. The patients’ positive perceptions of their alliance with their clinician and their satisfaction with treatment was significantly associated with more days of abstinence from alcohol during treatment. Two clinician factors clinician confidence in the Medical Management treatment and flexibility in delivering Medical Management were also associated with better patient outcomes. CONCLUSIONS Medically trained clinicians with minimal specialty training in alcohol dependence treatments were able to deliver a brief and effective medication management intervention that was designed to be consistent with primary care practice.