Strategies for Fidelity Monitoring a Solution-Focused Brief Intervention in a Randomized Clinical Trial

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Method: A mixed methods concurrent process evaluation was utilized within the context of a randomized clinical trial to assess intervention fidelity for a Solution Focused Brief Therapy (SFBT) intervention implemented within an IC model. Data was collected through 1) participant surveys, 2) self-report surveys with the interventionist, and 3) data from patient charts. Descriptive statistics in addition to repeated measures ANOVA were utilized to acquire quantitative data. Qualitative data was acquired through content analyses and data triangulation was used to present findings. Results: The average SFBT intervention was 24.6 minutes with a range of 15-30 minutes. Of the 34 participants in the intervention group, 33 completed all 3 SFBT sessions. The majority of visits were weekly follow-ups (53.9%), followed by biweekly follow-ups (28.2%), and the remaining 3-week follow-ups (5.1%). The interventionist utilized session templates, and a self-report checklist to monitor intervention integrity. A SFBT scale was utilized to analyze the uptake of SFBT skills and there was a significant difference between those in the SFBT group and the treatment-as-usual group ( F [1, 64] = 22.7, p<.001): mean difference, 15.1 [95% CI, 11.2- 18.9]. Conclusion: Our study examined fidelity efficiently and comprehensively and provides a foundation for studies interested in fidelity monitoring of SFBT interventions as well as behavioral interventions within IC models. Trial Registration: The study was pre-registered at ClinicalTrials.gov Identifier: NCT05838222 on 01/05/2023. behavioral intervention depression primary care integrated behavioral health comorbid disorders fidelity Figures Figure 1 Contributions to the Literature Our paper operationalizes and analyzes implementation tools to measure fidelity for a Solution Focused Brief Therapy Intervention. Our paper describes a novel tool to measure participant growth in understanding and application of the Solution Focused Brief Therapy intervention. We operationalize and analyze novel methods for measuring fidelity within an integrated care model. We use Bellg and colleagues (2004) framework to describe our methods for measuring fidelity comprehensively and sustainably and therefore provide a model for future fidelity research studies. Background Depression and chronic medical conditions frequently co-occur and, when unaddressed, have negative physical and mental health consequences 1 , 2 . Integrated care (IC) models have emerged to expand healthcare teams to better address patients’ physical and psychosocial needs by incorporating behavioral health professionals (BHPs) within traditional medical teams 3 – 6 . Within IC models, BHPs modify evidence-based behavioral treatments (50–60 minutes on average for traditional mental health visits) to align with a 15-30-minute primary care (PC) visit type 5 – 7 . Also, BHPs see patients in treatment “episodes” with an average of 2–3 visits per patient typically occurring over 1–2 months compared to traditional mental health visits which utilize weekly follow-ups for several months, and sometimes years 5 , 6 . Behavioral interventions, therefore, tend to be more targeted, less problem-focused, and more flexible when compared to traditional mental health approaches. There are few studies which have formally operationalized and tested behavioral interventions for IC models 8 , 9 . Existing studies have adapted and tested Acceptance and Commitment Therapy (ACT) 8 , 10 and Cognitive Behavioral Therapy 9 within IC models. There are, however, alternative behavioral interventions, such as Solution Focused Brief Therapy (SFBT), which are flexible and have strong theoretical alignment with PC settings but have not been tested within IC models. There is therefore a research need to operationalize and examine the use of SFBT for IC models. Similar to ACT, SFBT refrains from utilizing a problem-focused framework when working with patients 11 . However, SFBT has unique theoretical foundations distinguishing it from ACT ( see Fig. 1 ) , including 1) focusing on strengths, 2) collaborating with patients to identify their preferred future, and 3) identifying and mobilizing patient strengths 12 . These core theoretical principles guide the main techniques used in SFBT; each designed to be flexibly implemented 12 . For example, when implementing SFBT interventions, BHPs tailor questions and utilize summary statements that are more precisely linked to the patient’s health goals to prompt patients to discuss their preferred future for their health, share personal strengths associated with their healthcare goals, and identify individuals to support their healthcare management. The flexible, non-manualized approach of SFBT lends itself well to integration within PC settings. However, this flexibility does introduce challenges for fidelity monitoring and intervention integrity within and across patient care encounters. Intervention fidelity can be defined as the degree to which the delivery of a treatment aligns with the treatment design/protocol. 13,14 There are several strategies for assessing intervention fidelity including 1) interventionist self-report checklists, 2) measuring the dose (frequency and duration) of the intervention, 3) exit interviews with participants, 4) observations from a trained staff member, and 5) measuring the patient’s responsiveness to the intervention (whether they learned or gained skills associated with intervention) 14 – 16 . Existing studies examining SFBT fidelity have utilized interventionist self-report, 17 and there are no other formal, empirically analyzed measures for analyzing SFBT. SFBT was recently adapted for use within an IC model to address depression among people with co-occurring health concerns (RCT, Trial Registration: NCT05838222, 01/05/2023). The pilot RCT demonstrated the efficacy of SFBT for reducing depression and anxiety and enhancing well-being for those with depression and co-occurring chronic illness (diabetes, hypertension, etc.). We conducted a secondary analysis of patient and interventionist data from this pilot trial to measure fidelity to an SFBT intervention within an IC model. In this study, the existing SFBT self-report checklist 17 was used alongside newly developed fidelity measures (i.e., intervention templates, and a SFBT outcomes scale). The current study seeks to 1) describe the methods used to assess SFBT fidelity throughout implementation, 2) present the results of both novel and standard intervention fidelity measures, and 3) utilize data triangulation to demonstrate the utility and feasibility of including multiple fidelity measures within a study. Methods A mixed methods concurrent process evaluation was conducted in parallel with the SFBT trial to assess intervention fidelity. Three primary sources of data collection were utilized including 1) surveys from participants, 2) surveys from the interventionist, and 3) data from patient charts. Data triangulation across each source was performed to assess fidelity to the SFBT model within a primary care setting. Setting and Study Population The study took place in a rural federal qualified health center (FQHC). The FQHC provided PC services alongside pharmacy and behavioral healthcare. Patients were eligible if they were: 1) 18 years or older, 2) proficient in English, 3) scored ≥ 10 on the Patient Health Questionnaire (PHQ-9), and 4) had at least one co-occurring health condition (i.e., hypertension, obesity, diabetes). Exclusion criteria included: 1) current suicidal ideation, 2) prior participation in solution-focused (SF) treatment, and 3) inability to comprehend the informed consent process. Data Collection Participants (n = 69) in both groups engaged in a total of three visits each. The interventionist performed the self-report SFBT checklist at the end of each of the SFBT interventions. In addition, the interventionist provided documentation detailing how the intervention was performed as well as the patient’s response to the SFBT intervention. The interventionist documented the amount of time that they spent with each patient in both groups and detailed the date of service. Patients in both groups performed the SFBT survey at the beginning of the first session and then at the end of the second and third sessions. In addition, the intervention group completed a survey on the acceptability, appropriateness, and feasibility of intervention at the end of their last session. Interventionist Integrity Measures and Strategies SFBI Self-Report Checklist The Solution-Focused Fidelity Instrument 17 includes a total of 13 questions utilizing a 7-point Likert scale ranging from “1 = not at all,” “3 = yes, but not clear enough,” and “7 = yes, clearly and specifically.” The scale includes self-assessment questions such as “I asked the client what they wanted out of today’s session” and “I asked exception/difference questions during today’s session.” The range for the total score on the SFBT checklist was 13–91. The scale has demonstrated good reliability (alpha = .83). Interventionist Training : The interventionist underwent training throughout the study. The interventionist’s training included: 1) a foundations of SFBT training session, 2) an advisory session with the trainer of the SFBT workshop, 3) two advanced booster sessions throughout the study, and 4) biweekly debrief meetings with a research mentor with expertise in SFBT. Intervention Frequency and Duration The interventionist 1) timed each session, 2) recorded the date of each session to measure visit frequency (visits also timed stamped in the medical record), and 3) tracked the number of sessions held with each participant in the intervention group (also included in medical record). The SFBT intervention was adapted to adhere to a visit structure utilized in an IC model (15 = 30 minutes; episodes of 2–3 visits). Descriptive statistics were calculated to analyze to assess intervention alignment. Patient Measures SFBT Core Constructs The SFBT scale was created by researchers to assess patient improvement in foundational SF traits including hope, connection to important people, self-acknowledged strengths, confidence in problem-solving, and confidence in a “good” future. These constructs were acquired from a content analysis of SFBT training manuals and materials 12 , 18 . The scale was provided at both baseline and after treatment completion. There was a total of 5 questions that utilized a 10-point scale resulting in a possible range of 0–50. The reliability of the SFBT questions was good with a Cronbach alpha of 0.82 at baseline and an alpha of 0.82 for outcome measures. Acceptability, Feasibility, and Appropriateness of Intervention Measure The Acceptability, Feasibility and Appropriateness measures were created by Weiner and colleagues based on Proctor’s implementation outcomes 19 , 20 . Each of these scales utilize the same 5-point Likert scale to analyze the acceptability, feasibility, and appropriateness of the SFBT intervention. The Likert scale ranges from “1 = completely disagree” to “5 = completely agree.” Participant responsiveness has been identified as an additional key measurement of fidelity and these measures were included as a result. 15 Measures from Patient Chart Charting Templates : A content analysis was performed to extract the essential ingredients of a SFBT intervention. Sources included the SFBT manual 12 , training materials from the SFBT Institute 18 , and advisory sessions with SFBT experts. From these sources, researchers created a template that guided the interventionist during each session, see Table 2 . The template included prompts such as: 1) opening sessions by asking “what has been better about your health?” 2) using open-ended questions to ask, “how have important people supported your health goals?” and 3) elucidating a solution-oriented perspective by asking “how have you been able to tell you have made progress toward your health goals?” The interventionist utilized this template to standardize the delivery of the SFBI to enhance intervention integrity. Chart Review The interventionist reviewed patient charts to assess intervention integrity, assess the patient response, and make modifications for future visits as needed. These reviews were also brought to weekly supervision meetings with an SFBT expert. Analysis Descriptive statistics were calculated regarding the average number of visits per participant, the average distance between visits, and the average intervention time length. In addition, descriptive statistics are provided summarizing the results from the SFBT fidelity checklist. Participant scores on the SFBT scale were assessed over time to identify their associated growth with core SFBT constructs, both groups received this scale at baseline and follow-up. Researchers utilized repeated-measures ANOVA to analyze the differences between groups and to assess change across SFBT domains. Results Researchers assessed the fidelity of the SFBT intervention by analyzing 1) the frequency and duration of the intervention, 2) assessing intervention alignment with SFBT active ingredients, 3) assessing whether participants acquired knowledge and skills needed to improve regarding core constructs of the SFBI, and 4) assessing acceptance, feasibility, and appropriateness of the intervention to better understand factors associated with patient responsiveness. Data triangulation was utilized to assess the overall fidelity of the SFBI. See Table 3 for a summary of the strategies used to analyze intervention fidelity. Intervention Frequency and Duration The average SFBT visit for individuals in the treatment group aligned with a 20–30-minute medical encounter (M = 24.69. SD = 3.98, Range = 15–30). Regarding the visit frequency, the majority (53.9%) of participants had 1-week follow-ups followed by 28.2% who had 2-week follow-ups and 5.1% with 3-week follow-ups. Only one participant was unable to complete all treatment sessions. See Table 1 for a detailed description of these results. Intervention Integrity The total mean score for the fidelity self-assessment was 81.85 with a SD of 4.88 meaning that the provider had an adherence rate of 89%, See Table 1 . There was a gradual increase in the interventionist’s adherence rate as evidenced by the fidelity self-assessment tool with a baseline adherence rate of 87% (79.43/91), 89% during the second session (81.15/91), and 90.4% (82.31/91) at the final session. Patient responsiveness Patients responded favorably regarding their acceptability of the intervention with mean scores of 4.92 with scores ranging from 4–5. In addition, patients rated the intervention as appropriate with mean scores of 4.89 with ranges from 4–5, and feasible with mean scores of 4.91 and scores ranging from 4–5. Patients indicated that the focus on strengths and solutions helped identify methods to solve problems regarding their depressive symptoms and health challenges. SFBI Core Constructs SFBT essential ingredients were utilized to create a scale representing the core constructs related to SFBT interventions. These constructs represent the foundational theories regarding how SFBT interventions facilitate change. Those in the treatment group had statistically significant increases regarding SF constructs when compared to the control group ( F [1, 64] = 22.7, p < .001): mean difference, 15.1 [95% CI, 11.2–18.9]. The corresponding effect size for the repeated measures ANOVA was large ( n 2 = .27) meaning that 27% of the difference between groups regarding SFBT constructs was explained by the intervention. Data Triangulation The high acceptability of the SFBT intervention (M = 4.92) aligns with data demonstrating low intervention attrition; 97% of patients in the treatment group attended 3/3 SFBT sessions. Strategies to maintain SFBT skills include chart review and advanced booster trainings and, in this study, led to increased intervention alignment with SFBT active ingredients (Session 1: M = 79.43: Session 2: M = 81.15: Session 3: M = 82.31). See Table 1 for detailed description of data triangulation. Discussion Fidelity monitoring is essential to ensuring that behavioral interventions align with treatment ingridients 13 , 22 . Within IC models, behavioral interventions are shorter and adhere to a primary care workflow 6 . The structure and flexibility of SFBT fit within the structure of IC models, but there are no existing studies which have examined the fidelity of a SFBT intervention for an IC model. Our study addressed this gap by operationalizing an intervention with a session length, frequency, and duration that fits within an IC model. In addition, the researchers created a SFBT outcomes scale to assess whether patients were improving in their knowledge and application of SFBT core constructs. The novel fidelity tools developed in this study may be used in addition to standard fidelity measures to provide a comprehensive method for SFBT fidelity monitoring tailored for use within IC models. Existing research on fidelity monitoring of SFBT interventions largely utilize the SFBT fidelity checklist, which relies on interventionist self-assessment 17 . The self-assessment scale has been utilized in research using SFBT among diverse populations including individuals with substance and alcohol use disorders 23 – 25 , children with Cerebral Palsy 26 , patients with HIV 27 , and children within the welfare system 28 , 29 , and how been found to be useful for acquiring a subjective interpretation of how intervention fidelity from the perspective of the interventionist. Though beneficial, utilizing clinician self-report is limited as it relies on the subjective appraisal of the clinician to rate their adherence to the intervention. This can be particularly problematic if the clinician perceives themselves as adhering to the model while performing the intervention with a lack of treatment integrity. Within our study, the utilization of charting templates helped increase SFBT adherence rates. In addition, our study was able to provide more objective results by measuring growth in SFBT core constructs. Additional existing studies utilized methods of observation 25 , performing content analyses of recorded interviews 24 , and tracking the treatment outcomes 27 . Kim and colleagues also cite the use of a SFBT session manual form that was utilized by observers to analyze intervention integrity 25 . These studies indicated that these methods were effective in identifying more objective measures of fidelity. Our study also measured outcomes as an indicator of intervention fidelity while also tracking growth in SFBT constructs. Future studies may incorporate recorded interviews with examples of charting templates included in our study to acquire more precise measures of fidelity. Participant observation, though beneficial, can be invasive to participants, costly, and time-consuming. Utilizing methods such as measuring growth in SFBT core constructs may provide a more efficient and objective approach to measuring SFBT fidelity. Our study builds on the foundation of research examining SFBT intervention fidelity. We were able to measure SFBT outcomes through our SFBT scale providing a more objective mechanism to measure growth and competence in SFBT constructs. Future studies with more power may also use this as a mediating variable to analyze whether SFBT interventions mediate the relationship between the intervention and the outcome of interest. Our study also operationalized an intervention template using SFBT manuals and training materials to increase the alignment with the SFBT protocol. Future studies can utilize this to measure growth in adherence rates and intervention integrity in clinical trials. Our study was also the first to assess the SFBT intervention alignment with an IC visit type and demonstrated that it is feasible to align a SFBT intervention within the context of an IC visit type. Our study demonstrated that individuals within the intervention group had significant growth in SFBT constructs such as future hope, self-perceived strengths, and confidence in solving problems. Maturing in the skills demonstrates SFBT knowledge, skills, and real-world utilization/implementation. The research foundation examining fidelity for behavioral interventions within IC models is limited. Existing studies have examined constructs such as dose and intervention adherence 30 and have elucidated core components of IC models from behavioral health providers utilizing a Delphi method 31 . There are fewer studies which examine the fidelity of specific behavioral interventions within IC models. Further, a systematic review examined behavioral intervention studies examining intervention fidelity and found that 13.9% of studies addressed fidelity through their study design, 33.8% through provider training, 90.7% through the delivery of treatment, and 15.3% through the enactment of treatment skills 32 . Further, O’Shea and colleagues (2016) indicate that a mere 3% of studies assessed fidelity comprehensively including at least one measurement for each of the 5 components described by Bellg and colleagues 14 . The lack of efforts to systematically assess the fidelity of behavioral interventions may reflect the fact that monitoring fidelity can include time-consuming strategies such as exit interviews, observation, and reviewing recordings of sessions, 33 activities that many may not have the resources to support. Our study measured each of the 5 domains while operationalizing sustainable and efficient strategies that researchers can utilize within behavioral intervention studies. Last, existing research has suggested that patients are more engaged and responsive when they are accepting of the intervention and identify it as appropriate and feasible. Our study demonstrated that the SFBT intervention was perceived as acceptable and feasible by participants and may have been a factor in reducing attrition. Conclusion Intervention fidelity for behavioral interventions within IC models is important to understand but rarely measured. Our study provides a template to analyze the fidelity of a SFBT intervention within an IC model comprehensively and efficiently. Future studies may combine these approaches with other best practices to include coding recorded interviews and exit interviews with participants. Declarations Ethics approval and consent to participate. The study received IRB approval from the University of Georgia. All participants signed an informed consent prior to participation in the study. Consent for publication. All participants in the study consented to have the deidentified data collected published. Human Ethics and Consent to Participate. The study received IRB approval from the University of Georgia (PROJECT00006727). All of the participants included within the study consented to participate in the study and were informed of their right to discontinue at any time. Availability of data and materials. The datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns but are available from the corresponding author on reasonable request. Competing interests. The authors declare that they have no competing interests. Funding. The primary author (ZC) received funds from the Solution Focused Brief Therapy Association to cover the cost of participant incentives. Authors' contributions. ZC conceptualized the project, engaged in funding acquisition, led the development of the methodology, performed data visualization, performed the formal analyses, and engaged in writing and editing the original and subsequent manuscript drafts. LJ supervised formal analyses, data visualization, and methodology. LJ also reviewed and edited the manuscript. Acknowledgements. Not applicable References Gilman SE, et al. Depression and mortality in a longitudinal study: 1952–2011. CMAJ. 2017;189:E1304–10. Bădescu S, et al. The association between Diabetes mellitus and Depression. J Med Life. 2016;9:120–5. Cooper Z, Zerden LDS, How. COVID-19 has impacted integrated care practice: lessons from the frontlines. Soc Work Health Care. 2021;60:146–56. Blount A. Integrated Primary Care: Organizing the Evidence. Families Syst Health. 2003;21:121–33. Robinson PJ, Reiter JT. Behavioral Consultation and Primary Care. 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Tables Table 1: Data Triangulation Fidelity Goal Data Source(s) used in Assessment Study Application Maintain Intervention Structure Ensure same treatment length for patients Chart review Average visit lengths by session: Session 1: 26.29 (SD: 5.33) Session 2: 25.76 (SD: 3.98) Session 3: 24.69 (SD: 3.09) Ensure same visit frequency for patients Chart review Date recorded in medical chart for each visit. Session1-Session 2: M=1.36, SD = 0.67 Session2-Session 3: M=1.44, SD = 0.45 Ensure Provider Competence Ensure interventionist has foundational training Clinician self-report Completed SFBT foundational training through the SFBT Institute+ Sustain interventionist’s SFBT skills Clinician self-report Completed booster training every 2x weeks+ Participated in biweekly meetings with SFBT mentor+ Monitor SFBT Integrity Interventionist to rate alignment with SFBT manual Clinician self-report The interventionist assessed their alignment with the SFBT after every session: Session 1: 79.43/91= 87% adherence rate Session 2: 81.15/91= 89% adherence rate Session 3: 82.31/91= 90.4% adherence rate Ensure consistency across sessions Chart review Use of charting template to standardize visits+ Ensure alignment with SFBT active ingredients at each session Chart review Embedded active ingredients and prompts from SFBT manual+ Assess Receipt of SFBT Intervention Enhance treatment receptiveness/engagement Patient surveys Assessed patient acceptability (M=4.92) as well as their perceptions of the feasibility (M=4.91) and appropriateness (M=4.89) of SFBT Assess patient understanding of SFBT approach Chart review Embed scaling questions in notes to assess confidence to perform SFBT goals+ Assess behavioral alignment with SFBT approach Chart review Include prompt within chart to open session asking “what’s better” to analyze behavioral changes made Enactment of Treatment Measure uptake in SFBT skills Patient surveys Assessed growth in core SFBT constructs (Baseline: M=27.29, SD=9.78: Outcome: M=34.97, SD=7.93) Measure change in other outcomes (i.e., well-being, depression) Patient surveys Assessed growth in Depression (Baseline: M=18.17: Outcome: M= 9.71) Assessed growth in Well-Being (Baseline: M=59.37: Outcome: M= 73.43) +Indicates that this was a strategy used but no data was collected or evaluated for this strategy Table 2: Template to Maintain Intervention Integrity Template Prompt Solution Focused Checklist Solution Focused Scaling Item Start with open-ended question asking the patient “what about your health has been better since we last met?” Eliciting exceptions to the problem the patient is experiencing. Awareness of Strengths/Improvements Follow with open ended question such as “How did you manage to make that improvement?” Provides indirect comment while eliciting patient talk regarding their strengths to improve health. Amplifies patient’s problem-solving ability Self-Acknowledgement/Awareness of Strengths Follow with open ended question asking, “How have important people in your life supported your health improvement?” Elicits patient acknowledgement of important people in their life and how they have supported their health. Connection to Important People Prompt patient to consider building on existing progress by asking, “how might you build on your progress and continue to improve your health?” Prompts patient to articulate behavioral changes to improve health. Confidence to solve problems and improve health. Ask scaling question: on a scale of 1-10 with 1 being not at all confident and 10 being completely confident, how confident are you that you can meet this goal? Follow with, What is the highest it has even been what was different? Prompts self-investigation of patient strengths and confidence to meet health goals. Confidence to solve problems and improve health. Confidence for a good future. Prompt patient to further operationalize their change goals by asking, “what is one way that you could make a small step toward ______ goal.” Prompts patient to further operationalize their change goal. Confidence in a good future. What are you most looking forward to once you meet _____ health goal? Elicits patient’s future hopes. Engages patient’s values. Patient hope. Hope for a good future. Additional SF Tips: Elicit strengths; use scaling questions; ask about patient hopes; amplify positive differences/ exceptions; elicit support and connection to others. Table 3: Strategies for Comprehensive Fidelity Monitoring using Bellg and Colleagues Model Domains of Treatment Fidelity Strategies to Analyze Fidelity Domain Design of Study Randomization of participants Utilize same visit frequency and duration for both groups Standardized scripts for visit introduction Training Providers Foundational SFBT training Consultation with SFBT experts Booster sessions for interventionist throughout study Biweekly meetings with SFBT mentor Delivery of Treatment SFBT self-assessment checklist SFBT charting template Content analysis of notes Standardized length and frequency Receipt of Treatment Scaling questions to assess patient’s understanding of SFBT skills and goals Engage patient to make their own goals that are subjectively meaningful for their health Enactment of Treatment Skills SFBT scale Measurement of outcomes Fidelity: Methods utilized to enhance treatment integrity by increasing the reliability and validity of the behavioral intervention. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4085224","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":284267856,"identity":"914f4c8a-1b4f-4d09-8716-f64500388375","order_by":0,"name":"Zach Cooper","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYHACNhiD8QGETiBeC7MByVrYJIjSIt9++NkDhhobOXP23mfVPL/sGPjZcwzwamHsSTM3YDiWZmzZc9zsNm9fMoNkzxv8WpgZctgkGBsOJ264kcZ2m7eHmcHgBgFb2PjfQLXcf8ZWzNtTz2BPSAuPBNwWNjZmnh+HGQwkCGiRkHhmJpEA9ksas+TchuM8EmeeFeDVIt+f/EziAzjEjjF+ePOnWo6/PXkDXi1gkADEYMcwtjHwEFYOAxD3/yFewygYBaNgFIwcAADc1z3L64HAwwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Georgia","correspondingAuthor":true,"prefix":"","firstName":"Zach","middleName":"","lastName":"Cooper","suffix":""},{"id":284267858,"identity":"d0ff59b2-aeda-45bb-b347-2f0710f18ec5","order_by":1,"name":"Leslie Johnson","email":"","orcid":"","institution":"Emory University","correspondingAuthor":false,"prefix":"","firstName":"Leslie","middleName":"","lastName":"Johnson","suffix":""}],"badges":[],"createdAt":"2024-03-12 16:14:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4085224/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4085224/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53881169,"identity":"6b20d836-c8d5-4a48-8b35-029eb2c5d994","added_by":"auto","created_at":"2024-04-01 17:52:03","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":907101,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSolution Focused Essential Ingredients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4085224/v1/4f7a686fd93064a50db2bb62.jpeg"},{"id":56916088,"identity":"709f0591-bcf4-4cfa-b60d-49d721b41714","added_by":"auto","created_at":"2024-05-22 06:23:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1619360,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4085224/v1/c8787ade-bde7-4225-a962-cf6ad89cf5d4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Strategies for Fidelity Monitoring a Solution-Focused Brief Intervention in a Randomized Clinical Trial","fulltext":[{"header":"Contributions to the Literature","content":"\u003cul\u003e\n \u003cli\u003eOur paper operationalizes and analyzes implementation tools to measure fidelity for a Solution Focused Brief Therapy Intervention.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003eOur paper describes a novel tool to measure participant growth in understanding and application of the Solution Focused Brief Therapy intervention.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003eWe operationalize and analyze novel methods for measuring fidelity within an integrated care model.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003eWe use Bellg and colleagues (2004) framework to describe our methods for measuring fidelity comprehensively and sustainably and therefore provide a model for future fidelity research studies.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eDepression and chronic medical conditions frequently co-occur and, when unaddressed, have negative physical and mental health consequences\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Integrated care (IC) models have emerged to expand healthcare teams to better address patients\u0026rsquo; physical and psychosocial needs by incorporating behavioral health professionals (BHPs) within traditional medical teams\u003csup\u003e\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Within IC models, BHPs modify evidence-based behavioral treatments (50\u0026ndash;60 minutes on average for traditional mental health visits) to align with a 15-30-minute primary care (PC) visit type\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Also, BHPs see patients in treatment \u0026ldquo;episodes\u0026rdquo; with an average of 2\u0026ndash;3 visits per patient typically occurring over 1\u0026ndash;2 months compared to traditional mental health visits which utilize weekly follow-ups for several months, and sometimes years\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Behavioral interventions, therefore, tend to be more targeted, less problem-focused, and more flexible when compared to traditional mental health approaches.\u003c/p\u003e \u003cp\u003eThere are few studies which have formally operationalized and tested behavioral interventions for IC models\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Existing studies have adapted and tested Acceptance and Commitment Therapy (ACT)\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and Cognitive Behavioral Therapy\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e within IC models. There are, however, alternative behavioral interventions, such as Solution Focused Brief Therapy (SFBT), which are flexible and have strong theoretical alignment with PC settings but have not been tested within IC models. There is therefore a research need to operationalize and examine the use of SFBT for IC models.\u003c/p\u003e \u003cp\u003eSimilar to ACT, SFBT refrains from utilizing a problem-focused framework when working with patients\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, SFBT has unique theoretical foundations distinguishing it from ACT (\u003cb\u003esee\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, including 1) focusing on strengths, 2) collaborating with patients to identify their preferred future, and 3) identifying and mobilizing patient strengths\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. These core theoretical principles guide the main techniques used in SFBT; each designed to be flexibly implemented\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. For example, when implementing SFBT interventions, BHPs tailor questions and utilize summary statements that are more precisely linked to the patient\u0026rsquo;s health goals to prompt patients to discuss their preferred future for their health, share personal strengths associated with their healthcare goals, and identify individuals to support their healthcare management. The flexible, non-manualized approach of SFBT lends itself well to integration within PC settings. However, this flexibility does introduce challenges for fidelity monitoring and intervention integrity within and across patient care encounters.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIntervention fidelity can be defined as the degree to which the delivery of a treatment aligns with the treatment design/protocol.\u003csup\u003e13,14\u003c/sup\u003e There are several strategies for assessing intervention fidelity including 1) interventionist self-report checklists, 2) measuring the dose (frequency and duration) of the intervention, 3) exit interviews with participants, 4) observations from a trained staff member, and 5) measuring the patient\u0026rsquo;s responsiveness to the intervention (whether they learned or gained skills associated with intervention)\u003csup\u003e\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Existing studies examining SFBT fidelity have utilized interventionist self-report,\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e and there are no other formal, empirically analyzed measures for analyzing SFBT.\u003c/p\u003e \u003cp\u003eSFBT was recently adapted for use within an IC model to address depression among people with co-occurring health concerns (RCT, Trial Registration: NCT05838222, 01/05/2023). The pilot RCT demonstrated the efficacy of SFBT for reducing depression and anxiety and enhancing well-being for those with depression and co-occurring chronic illness (diabetes, hypertension, etc.). We conducted a secondary analysis of patient and interventionist data from this pilot trial to measure fidelity to an SFBT intervention within an IC model. In this study, the existing SFBT self-report checklist\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e was used alongside newly developed fidelity measures (i.e., intervention templates, and a SFBT outcomes scale). The current study seeks to 1) describe the methods used to assess SFBT fidelity throughout implementation, 2) present the results of both novel and standard intervention fidelity measures, and 3) utilize data triangulation to demonstrate the utility and feasibility of including multiple fidelity measures within a study.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA mixed methods concurrent process evaluation was conducted in parallel with the SFBT trial to assess intervention fidelity. Three primary sources of data collection were utilized including 1) surveys from participants, 2) surveys from the interventionist, and 3) data from patient charts. Data triangulation across each source was performed to assess fidelity to the SFBT model within a primary care setting.\u003c/p\u003e\n\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eSetting and Study Population\u003c/h2\u003e\n \u003cp\u003eThe study took place in a rural federal qualified health center (FQHC). The FQHC provided PC services alongside pharmacy and behavioral healthcare. Patients were eligible if they were: 1) 18 years or older, 2) proficient in English, 3) scored\u0026thinsp;\u0026ge;\u0026thinsp;10 on the Patient Health Questionnaire (PHQ-9), and 4) had at least one co-occurring health condition (i.e., hypertension, obesity, diabetes). Exclusion criteria included: 1) current suicidal ideation, 2) prior participation in solution-focused (SF) treatment, and 3) inability to comprehend the informed consent process.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003eData Collection\u003c/h2\u003e\n \u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;69) in both groups engaged in a total of three visits each. The interventionist performed the self-report SFBT checklist at the end of each of the SFBT interventions. In addition, the interventionist provided documentation detailing how the intervention was performed as well as the patient\u0026rsquo;s response to the SFBT intervention. The interventionist documented the amount of time that they spent with each patient in both groups and detailed the date of service. Patients in both groups performed the SFBT survey at the beginning of the first session and then at the end of the second and third sessions. In addition, the intervention group completed a survey on the acceptability, appropriateness, and feasibility of intervention at the end of their last session.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003eInterventionist Integrity Measures and Strategies\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eSFBI Self-Report Checklist\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe Solution-Focused Fidelity Instrument\u003csup\u003e\u003cspan\u003e17\u003c/span\u003e\u003c/sup\u003e includes a total of 13 questions utilizing a 7-point Likert scale ranging from \u0026ldquo;1\u0026thinsp;=\u0026thinsp;not at all,\u0026rdquo; \u0026ldquo;3\u0026thinsp;=\u0026thinsp;yes, but not clear enough,\u0026rdquo; and \u0026ldquo;7\u0026thinsp;=\u0026thinsp;yes, clearly and specifically.\u0026rdquo; The scale includes self-assessment questions such as \u0026ldquo;I asked the client what they wanted out of today\u0026rsquo;s session\u0026rdquo; and \u0026ldquo;I asked exception/difference questions during today\u0026rsquo;s session.\u0026rdquo; The range for the total score on the SFBT checklist was 13\u0026ndash;91. The scale has demonstrated good reliability (alpha\u0026thinsp;=\u0026thinsp;.83).\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan type=\"ItalicUnderline\" name=\"Emphasis\"\u003eInterventionist Training\u003c/span\u003e: The interventionist underwent training throughout the study. The interventionist\u0026rsquo;s training included: 1) a foundations of SFBT training session, 2) an advisory session with the trainer of the SFBT workshop, 3) two advanced booster sessions throughout the study, and 4) biweekly debrief meetings with a research mentor with expertise in SFBT.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention Frequency and Duration\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe interventionist 1) timed each session, 2) recorded the date of each session to measure visit frequency (visits also timed stamped in the medical record), and 3) tracked the number of sessions held with each participant in the intervention group (also included in medical record). The SFBT intervention was adapted to adhere to a visit structure utilized in an IC model (15\u0026thinsp;=\u0026thinsp;30 minutes; episodes of 2\u0026ndash;3 visits). Descriptive statistics were calculated to analyze to assess intervention alignment.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003ePatient Measures\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eSFBT Core Constructs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe SFBT scale was created by researchers to assess patient improvement in foundational SF traits including hope, connection to important people, self-acknowledged strengths, confidence in problem-solving, and confidence in a\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;good\u0026rdquo; future. These constructs were acquired from a content analysis of SFBT training manuals and materials\u003csup\u003e\u003cspan\u003e12\u003c/span\u003e,\u003cspan\u003e18\u003c/span\u003e\u003c/sup\u003e. The scale was provided at both baseline and after treatment completion. There was a total of 5 questions that utilized a 10-point scale resulting in a possible range of 0\u0026ndash;50. The reliability of the SFBT questions was good with a Cronbach alpha of 0.82 at baseline and an alpha of 0.82 for outcome measures.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAcceptability, Feasibility, and Appropriateness of Intervention Measure\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe Acceptability, Feasibility and Appropriateness measures were created by Weiner and colleagues based on Proctor\u0026rsquo;s implementation outcomes\u003csup\u003e\u003cspan\u003e19\u003c/span\u003e,\u003cspan\u003e20\u003c/span\u003e\u003c/sup\u003e. Each of these scales utilize the same 5-point Likert scale to analyze the acceptability, feasibility, and appropriateness of the SFBT intervention. The Likert scale ranges from \u0026ldquo;1\u0026thinsp;=\u0026thinsp;completely disagree\u0026rdquo; to \u0026ldquo;5\u0026thinsp;=\u0026thinsp;completely agree.\u0026rdquo; Participant responsiveness has been identified as an additional key measurement of fidelity and these measures were included as a result.\u003csup\u003e\u003cspan\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003eMeasures from Patient Chart\u003c/h2\u003e\n \u003cp\u003e\u003cspan type=\"ItalicUnderline\" name=\"Emphasis\"\u003eCharting Templates\u003c/span\u003e: A content analysis was performed to extract the essential ingredients of a SFBT intervention. Sources included the SFBT manual\u003csup\u003e\u003cspan\u003e12\u003c/span\u003e\u003c/sup\u003e, training materials from the SFBT Institute\u003csup\u003e\u003cspan\u003e18\u003c/span\u003e\u003c/sup\u003e, and advisory sessions with SFBT experts. From these sources, researchers created a template that guided the interventionist during each session, \u003cstrong\u003esee\u003c/strong\u003e Table \u003cspan\u003e2\u003c/span\u003e. The template included prompts such as: 1) opening sessions by asking \u0026ldquo;what has been better about your health?\u0026rdquo; 2) using open-ended questions to ask, \u0026ldquo;how have important people supported your health goals?\u0026rdquo; and 3) elucidating a solution-oriented perspective by asking \u0026ldquo;how have you been able to tell you have made progress toward your health goals?\u0026rdquo; The interventionist utilized this template to standardize the delivery of the SFBI to enhance intervention integrity.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eChart Review\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe interventionist reviewed patient charts to assess intervention integrity, assess the patient response, and make modifications for future visits as needed. These reviews were also brought to weekly supervision meetings with an SFBT expert.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eAnalysis\u003c/h2\u003e\n \u003cp\u003eDescriptive statistics were calculated regarding the average number of visits per participant, the average distance between visits, and the average intervention time length. In addition, descriptive statistics are provided summarizing the results from the SFBT fidelity checklist. Participant scores on the SFBT scale were assessed over time to identify their associated growth with core SFBT constructs, both groups received this scale at baseline and follow-up. Researchers utilized repeated-measures ANOVA to analyze the differences between groups and to assess change across SFBT domains.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eResearchers assessed the fidelity of the SFBT intervention by analyzing 1) the frequency and duration of the intervention, 2) assessing intervention alignment with SFBT active ingredients, 3) assessing whether participants acquired knowledge and skills needed to improve regarding core constructs of the SFBI, and 4) assessing acceptance, feasibility, and appropriateness of the intervention to better understand factors associated with patient responsiveness. Data triangulation was utilized to assess the overall fidelity of the SFBI. See Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e for a summary of the strategies used to analyze intervention fidelity.\u003c/p\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eIntervention Frequency and Duration\u003c/h2\u003e\n \u003cp\u003eThe average SFBT visit for individuals in the treatment group aligned with a 20\u0026ndash;30-minute medical encounter (M\u0026thinsp;=\u0026thinsp;24.69. SD\u0026thinsp;=\u0026thinsp;3.98, Range\u0026thinsp;=\u0026thinsp;15\u0026ndash;30). Regarding the visit frequency, the majority (53.9%) of participants had 1-week follow-ups followed by 28.2% who had 2-week follow-ups and 5.1% with 3-week follow-ups. Only one participant was unable to complete all treatment sessions. See Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e for a detailed description of these results.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eIntervention Integrity\u003c/h2\u003e\n \u003cp\u003eThe total mean score for the fidelity self-assessment was 81.85 with a SD of 4.88 meaning that the provider had an adherence rate of 89%, See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. There was a gradual increase in the interventionist\u0026rsquo;s adherence rate as evidenced by the fidelity self-assessment tool with a baseline adherence rate of 87% (79.43/91), 89% during the second session (81.15/91), and 90.4% (82.31/91) at the final session.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient responsiveness\u003c/h2\u003e\n \u003cp\u003ePatients responded favorably regarding their acceptability of the intervention with mean scores of 4.92 with scores ranging from 4\u0026ndash;5. In addition, patients rated the intervention as appropriate with mean scores of 4.89 with ranges from 4\u0026ndash;5, and feasible with mean scores of 4.91 and scores ranging from 4\u0026ndash;5. Patients indicated that the focus on strengths and solutions helped identify methods to solve problems regarding their depressive symptoms and health challenges.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eSFBI Core Constructs\u003c/h2\u003e\n \u003cp\u003eSFBT essential ingredients were utilized to create a scale representing the core constructs related to SFBT interventions. These constructs represent the foundational theories regarding how SFBT interventions facilitate change. Those in the treatment group had statistically significant increases regarding SF constructs when compared to the control group (\u003cem\u003eF\u003c/em\u003e [1, 64]\u0026thinsp;=\u0026thinsp;22.7, p\u0026thinsp;\u0026lt;\u0026thinsp;.001): mean difference, 15.1 [95% CI, 11.2\u0026ndash;18.9]. The corresponding effect size for the repeated measures ANOVA was large (\u003cem\u003en\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.27) meaning that 27% of the difference between groups regarding SFBT constructs was explained by the intervention.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eData Triangulation\u003c/h2\u003e\n \u003cp\u003eThe high acceptability of the SFBT intervention (M\u0026thinsp;=\u0026thinsp;4.92) aligns with data demonstrating low intervention attrition; 97% of patients in the treatment group attended 3/3 SFBT sessions. Strategies to maintain SFBT skills include chart review and advanced booster trainings and, in this study, led to increased intervention alignment with SFBT active ingredients (Session 1: M\u0026thinsp;=\u0026thinsp;79.43: Session 2: M\u0026thinsp;=\u0026thinsp;81.15: Session 3: M\u0026thinsp;=\u0026thinsp;82.31). See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e for detailed description of data triangulation.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFidelity monitoring is essential to ensuring that behavioral interventions align with treatment ingridients\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Within IC models, behavioral interventions are shorter and adhere to a primary care workflow\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The structure and flexibility of SFBT fit within the structure of IC models, but there are no existing studies which have examined the fidelity of a SFBT intervention for an IC model. Our study addressed this gap by operationalizing an intervention with a session length, frequency, and duration that fits within an IC model. In addition, the researchers created a SFBT outcomes scale to assess whether patients were improving in their knowledge and application of SFBT core constructs. The novel fidelity tools developed in this study may be used in addition to standard fidelity measures to provide a comprehensive method for SFBT fidelity monitoring tailored for use within IC models.\u003c/p\u003e \u003cp\u003eExisting research on fidelity monitoring of SFBT interventions largely utilize the SFBT fidelity checklist, which relies on interventionist self-assessment\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The self-assessment scale has been utilized in research using SFBT among diverse populations including individuals with substance and alcohol use disorders\u003csup\u003e\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, children with Cerebral Palsy\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, patients with HIV\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, and children within the welfare system\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, and how been found to be useful for acquiring a subjective interpretation of how intervention fidelity from the perspective of the interventionist. Though beneficial, utilizing clinician self-report is limited as it relies on the subjective appraisal of the clinician to rate their adherence to the intervention. This can be particularly problematic if the clinician perceives themselves as adhering to the model while performing the intervention with a lack of treatment integrity. Within our study, the utilization of charting templates helped increase SFBT adherence rates. In addition, our study was able to provide more objective results by measuring growth in SFBT core constructs.\u003c/p\u003e \u003cp\u003eAdditional existing studies utilized methods of observation\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, performing content analyses of recorded interviews\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, and tracking the treatment outcomes\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Kim and colleagues also cite the use of a SFBT session manual form that was utilized by observers to analyze intervention integrity\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. These studies indicated that these methods were effective in identifying more objective measures of fidelity. Our study also measured outcomes as an indicator of intervention fidelity while also tracking growth in SFBT constructs. Future studies may incorporate recorded interviews with examples of charting templates included in our study to acquire more precise measures of fidelity. Participant observation, though beneficial, can be invasive to participants, costly, and time-consuming. Utilizing methods such as measuring growth in SFBT core constructs may provide a more efficient and objective approach to measuring SFBT fidelity.\u003c/p\u003e \u003cp\u003eOur study builds on the foundation of research examining SFBT intervention fidelity. We were able to measure SFBT outcomes through our SFBT scale providing a more objective mechanism to measure growth and competence in SFBT constructs. Future studies with more power may also use this as a mediating variable to analyze whether SFBT interventions mediate the relationship between the intervention and the outcome of interest. Our study also operationalized an intervention template using SFBT manuals and training materials to increase the alignment with the SFBT protocol. Future studies can utilize this to measure growth in adherence rates and intervention integrity in clinical trials. Our study was also the first to assess the SFBT intervention alignment with an IC visit type and demonstrated that it is feasible to align a SFBT intervention within the context of an IC visit type. Our study demonstrated that individuals within the intervention group had significant growth in SFBT constructs such as future hope, self-perceived strengths, and confidence in solving problems. Maturing in the skills demonstrates SFBT knowledge, skills, and real-world utilization/implementation.\u003c/p\u003e \u003cp\u003eThe research foundation examining fidelity for behavioral interventions within IC models is limited. Existing studies have examined constructs such as dose and intervention adherence\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e and have elucidated core components of IC models from behavioral health providers utilizing a Delphi method\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. There are fewer studies which examine the fidelity of specific behavioral interventions within IC models. Further, a systematic review examined behavioral intervention studies examining intervention fidelity and found that 13.9% of studies addressed fidelity through their study design, 33.8% through provider training, 90.7% through the delivery of treatment, and 15.3% through the enactment of treatment skills\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Further, O\u0026rsquo;Shea and colleagues (2016) indicate that a mere 3% of studies assessed fidelity comprehensively including at least one measurement for each of the 5 components described by Bellg and colleagues\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The lack of efforts to systematically assess the fidelity of behavioral interventions may reflect the fact that monitoring fidelity can include time-consuming strategies such as exit interviews, observation, and reviewing recordings of sessions,\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e activities that many may not have the resources to support. Our study measured each of the 5 domains while operationalizing sustainable and efficient strategies that researchers can utilize within behavioral intervention studies.\u003c/p\u003e \u003cp\u003eLast, existing research has suggested that patients are more engaged and responsive when they are accepting of the intervention and identify it as appropriate and feasible. Our study demonstrated that the SFBT intervention was perceived as acceptable and feasible by participants and may have been a factor in reducing attrition.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIntervention fidelity for behavioral interventions within IC models is important to understand but rarely measured. Our study provides a template to analyze the fidelity of a SFBT intervention within an IC model comprehensively and efficiently. Future studies may combine these approaches with other best practices to include coding recorded interviews and exit interviews with participants.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u0026nbsp;\u003c/strong\u003eThe study received IRB approval from the University of Georgia. All participants signed an informed consent prior to participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u0026nbsp;\u003c/strong\u003eAll participants in the study consented to have the deidentified data collected published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate.\u0026nbsp;\u003c/strong\u003eThe study received IRB approval from the University of Georgia (PROJECT00006727). All of the participants included within the study consented to participate in the study and were informed of their right to discontinue at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials.\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests.\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u0026nbsp;\u003c/strong\u003eThe primary author (ZC) received funds from the Solution Focused Brief Therapy Association to cover the cost of participant incentives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions.\u0026nbsp;\u003c/strong\u003eZC conceptualized the project, engaged in funding acquisition, led the development of the methodology, performed data visualization, performed the formal analyses, and engaged in writing and editing the original and subsequent manuscript drafts. LJ supervised formal analyses, data visualization, and methodology. LJ also reviewed and edited the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements.\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGilman SE, et al. Depression and mortality in a longitudinal study: 1952\u0026ndash;2011. CMAJ. 2017;189:E1304\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBădescu S, et al. The association between Diabetes mellitus and Depression. J Med Life. 2016;9:120\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooper Z, Zerden LDS, How. COVID-19 has impacted integrated care practice: lessons from the frontlines. Soc Work Health Care. 2021;60:146\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlount A. Integrated Primary Care: Organizing the Evidence. 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Foundations Solution-Focused \u0026middot; Solution-Focused Therapy Institute. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://solutionfocused.net/foundations-course/\u003c/span\u003e\u003cspan address=\"https://solutionfocused.net/foundations-course/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor E, et al. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health. 2011;38:65\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner BJ, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12:108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrisko JW, Maschi T. Content Analysis. Oxford University Press; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMowbray CT, Holter MC, Teague GB, Bybee D. Fidelity Criteria: Development, Measurement, and Validation. Am J Evaluation. 2003;24:315\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JS, Brook J, Akin BA. Solution-Focused Brief Therapy With Substance-Using Individuals: A Randomized Controlled Trial Study. Res Social Work Pract. 2018;28:452\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGonz\u0026aacute;lez Suitt K, Geraldo P, Estay M, Franklin C. Solution-Focused Brief Therapy for Individuals With Alcohol Use Disorders in Chile. Res Social Work Pract. 2019;29:19\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JS, Brook J, Akin B. Randomized Controlled Trial of Solution-Focused Brief Therapy for Substance-Use-Disorder-Affected Parents Involved in the Child Welfare System. J Soc Social Work Res. 2021;12:545\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwellnus H, King G, Baldwin P, Keenan S, Hartman LR. A Solution-Focused Coaching Intervention with Children and Youth with Cerebral Palsy to Achieve Participation-Oriented Goals. Phys Occup Ther Pediatr. 2020;40:423\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYates H, Lee S. Fidelity Monitoring in the Solution Focused Wellness for HIV (SFWH) Intervention for Women. J Solut Focused Practices 5, (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedina A, Beyebach M, Garc\u0026iacute;a FE. Effectiveness and cost-effectiveness of a solution-focused intervention in child protection services. Child Youth Serv Rev. 2022;143:106703.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JS, Akin BA, Brook J. Solution-focused brief therapy to improve child well-being and family functioning outcomes with substance using parents in the child welfare system. Dev Child Welf. 2019;1:124\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta A, et al. Implementation fidelity to a behavioral diabetes prevention intervention in two New York City safety net primary care practices. BMC Public Health. 2023;23:575.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeehler GP, Funderburk JS, Possemato K, Vair CL. Developing a measure of provider adherence to improve the implementation of behavioral health services in primary care: a Delphi study. Implement Sci. 2013;8:19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Shea O, McCormick R, Bradley JM, O\u0026rsquo;Neill B. Fidelity review: a scoping review of the methods used to evaluate treatment fidelity in behavioural change interventions. Phys Therapy Reviews. 2016;21:207\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGinsburg LR, et al. Fidelity is not easy! Challenges and guidelines for assessing fidelity in complex interventions. Trials. 2021;22:372.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Data Triangulation\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFidelity Goal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eData Source(s) used in Assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Application\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.61538461538461%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaintain Intervention Structure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eEnsure same treatment length for patients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eChart review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eAverage visit lengths by session:\u003c/p\u003e\n \u003cp\u003eSession 1: 26.29 (SD: 5.33)\u003c/p\u003e\n \u003cp\u003eSession 2: 25.76 (SD: 3.98)\u003c/p\u003e\n \u003cp\u003eSession 3: 24.69 (SD: 3.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eEnsure same visit frequency for patients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eChart review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eDate recorded in medical chart for each visit.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSession1-Session 2: M=1.36, SD = 0.67\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSession2-Session 3: M=1.44, SD = 0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.61538461538461%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnsure Provider Competence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eEnsure interventionist has foundational training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eClinician self-report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eCompleted SFBT foundational training through the SFBT Institute+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eSustain interventionist\u0026rsquo;s SFBT skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eClinician self-report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eCompleted booster training every 2x weeks+\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eParticipated in biweekly meetings with SFBT mentor+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.61538461538461%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonitor SFBT Integrity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eInterventionist to rate alignment with SFBT manual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eClinician self-report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eThe interventionist assessed their alignment with the SFBT after every session:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSession 1: 79.43/91= 87% adherence rate\u003c/p\u003e\n \u003cp\u003eSession 2: 81.15/91= 89% adherence rate\u003c/p\u003e\n \u003cp\u003eSession 3: 82.31/91= 90.4% adherence rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eEnsure consistency across sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eChart review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eUse of charting template to standardize visits+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eEnsure alignment with SFBT active ingredients at each session\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eChart review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eEmbedded active ingredients and prompts from SFBT manual+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.61538461538461%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssess Receipt of SFBT Intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eEnhance treatment receptiveness/engagement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003ePatient surveys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eAssessed patient acceptability (M=4.92) as well as their perceptions of the feasibility (M=4.91) and appropriateness (M=4.89) of SFBT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eAssess patient understanding of SFBT approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eChart review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eEmbed scaling questions in notes to assess confidence to perform SFBT goals+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eAssess behavioral alignment with SFBT approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eChart review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eInclude prompt within chart to open session asking \u0026ldquo;what\u0026rsquo;s better\u0026rdquo; to analyze behavioral changes made\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.61538461538461%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnactment of Treatment \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eMeasure uptake in SFBT skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003ePatient surveys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eAssessed growth in core SFBT constructs (Baseline: M=27.29, SD=9.78: Outcome: M=34.97, SD=7.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eMeasure change in other outcomes (i.e., well-being, depression)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003ePatient surveys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.38461538461539%\" valign=\"top\"\u003e\n \u003cp\u003eAssessed growth in Depression (Baseline: M=18.17: Outcome: M= 9.71)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAssessed growth in Well-Being\u003c/p\u003e\n \u003cp\u003e(Baseline: M=59.37: Outcome: M= 73.43)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e+Indicates that this was a strategy used but no data was collected or evaluated for this strategy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Template to Maintain Intervention Integrity\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"714\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.697054698457222%\" valign=\"top\"\u003e\n \u003cp\u003eTemplate Prompt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eSolution Focused Checklist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eSolution Focused Scaling Item\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.42075736325385693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.697054698457222%\" valign=\"top\"\u003e\n \u003cp\u003eStart with open-ended question asking the patient \u0026ldquo;what about your health has been better since we last met?\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eEliciting exceptions to the problem the patient is experiencing.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eAwareness of Strengths/Improvements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.42075736325385693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.697054698457222%\" valign=\"top\"\u003e\n \u003cp\u003eFollow with open ended question such as \u0026ldquo;How did you manage to make that improvement?\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eProvides indirect comment while eliciting patient talk regarding their strengths to improve health. Amplifies patient\u0026rsquo;s problem-solving ability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-Acknowledgement/Awareness of Strengths\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.42075736325385693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.697054698457222%\" valign=\"top\"\u003e\n \u003cp\u003eFollow with open ended question asking, \u0026ldquo;How have important people in your life supported your health improvement?\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eElicits patient acknowledgement of important people in their life and how they have supported their health.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eConnection to Important People\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.42075736325385693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.697054698457222%\" valign=\"top\"\u003e\n \u003cp\u003ePrompt patient to consider building on existing progress by asking, \u0026ldquo;how might you build on your progress and continue to improve your health?\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003ePrompts patient to articulate behavioral changes to improve health. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eConfidence to solve problems and improve health.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.42075736325385693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.697054698457222%\" valign=\"top\"\u003e\n \u003cp\u003eAsk scaling question: on a scale of 1-10 with 1 being not at all confident and 10 being completely confident, how confident are you that you can meet this goal?\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow with, What is the highest it has even been what was different?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003ePrompts self-investigation of patient strengths and confidence to meet health goals.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eConfidence to solve problems and improve health.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eConfidence for a good future.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.42075736325385693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.697054698457222%\" valign=\"top\"\u003e\n \u003cp\u003ePrompt patient to further operationalize their change goals by asking, \u0026ldquo;what is one way that you could make a small step toward \u003cstrong\u003e\u003cu\u003e______\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u0026nbsp; goal.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003ePrompts patient to further operationalize their change goal.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eConfidence in a good future.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.42075736325385693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.697054698457222%\" valign=\"top\"\u003e\n \u003cp\u003eWhat are you most looking forward to once you meet _____ health goal?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003eElicits patient\u0026rsquo;s future hopes. Engages patient\u0026rsquo;s values.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.94109396914446%\" valign=\"top\"\u003e\n \u003cp\u003ePatient hope. Hope for a good future.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.42075736325385693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdditional SF Tips: Elicit strengths; use scaling questions; ask about patient hopes; amplify positive differences/ exceptions; elicit support and connection to others.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Strategies for Comprehensive Fidelity Monitoring using Bellg and Colleagues Model\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomains of Treatment Fidelity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrategies to Analyze Fidelity Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003eDesign of Study\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eRandomization of participants\u003c/li\u003e\n \u003cli\u003eUtilize same visit frequency and duration for both groups\u003c/li\u003e\n \u003cli\u003eStandardized scripts for visit introduction\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003eTraining Providers\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eFoundational SFBT training\u003c/li\u003e\n \u003cli\u003eConsultation with SFBT experts\u003c/li\u003e\n \u003cli\u003eBooster sessions for interventionist throughout study\u003c/li\u003e\n \u003cli\u003eBiweekly meetings with SFBT mentor\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003eDelivery of Treatment\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eSFBT self-assessment checklist\u003c/li\u003e\n \u003cli\u003eSFBT charting template\u003c/li\u003e\n \u003cli\u003eContent analysis of notes\u003c/li\u003e\n \u003cli\u003eStandardized length and frequency\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003eReceipt of Treatment\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eScaling questions to assess patient\u0026rsquo;s understanding of SFBT skills and goals\u003c/li\u003e\n \u003cli\u003eEngage patient to make their own goals that are subjectively meaningful for their health\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003col\u003e\n \u003cli\u003eEnactment of Treatment Skills\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eSFBT scale\u003c/li\u003e\n \u003cli\u003eMeasurement of outcomes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFidelity: Methods utilized to enhance treatment integrity by increasing the reliability and validity of the behavioral intervention.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"behavioral intervention, depression, primary care, integrated behavioral health, comorbid disorders, fidelity","lastPublishedDoi":"10.21203/rs.3.rs-4085224/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4085224/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIntegrated Care (IC) models that include behavioral health providers to enhance patient care have increased, but the current mechanisms to analyze the efficacy and fidelity of behavioral interventions within IC models are limited.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003eA mixed methods concurrent process evaluation was utilized within the context of a randomized clinical trial to assess intervention fidelity for a Solution Focused Brief Therapy (SFBT) intervention implemented within an IC model. Data was collected through 1) participant surveys, 2) self-report surveys with the interventionist, and 3) data from patient charts. Descriptive statistics in addition to repeated measures ANOVA were utilized to acquire quantitative data. Qualitative data was acquired through content analyses and data triangulation was used to present findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe average SFBT intervention was 24.6 minutes with a range of 15-30 minutes. Of the 34 participants in the intervention group, 33 completed all 3 SFBT sessions. The majority of visits were weekly follow-ups (53.9%), followed by biweekly follow-ups (28.2%), and the remaining 3-week follow-ups (5.1%). The interventionist utilized session templates, and a self-report checklist to monitor intervention integrity. A SFBT scale was utilized to analyze the uptake of SFBT skills and there was a significant difference between those in the SFBT group and the treatment-as-usual group (\u003cem\u003eF\u003c/em\u003e [1, 64] = 22.7, p\u0026lt;.001): mean difference, 15.1 [95% CI, 11.2- 18.9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOur study examined fidelity efficiently and comprehensively and provides a foundation for studies interested in fidelity monitoring of SFBT interventions as well as behavioral interventions within IC models.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration: \u003c/strong\u003eThe study was pre-registered at ClinicalTrials.gov Identifier: NCT05838222\u003cem\u003e \u003c/em\u003eon\u003cem\u003e \u003c/em\u003e01/05/2023.\u003c/p\u003e","manuscriptTitle":"Strategies for Fidelity Monitoring a Solution-Focused Brief Intervention in a Randomized Clinical Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-01 17:51:58","doi":"10.21203/rs.3.rs-4085224/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c6d3c46c-ca17-4dd4-b471-c283479a4101","owner":[],"postedDate":"April 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-22T06:15:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-01 17:51:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4085224","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4085224","identity":"rs-4085224","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}