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As we have suggested elsewhere (Schoenwald et al., 2011a), the purposes for which adherence measurement methods are used in routine clinical practice may differ from those for which the methods were originally developed. Measurement methods for high stakes purposes such as decision making by third party purchasers regarding program funding or de-funding must be adequate to the task. The criteria for the adequacy of measurement methods – that is, requirements for consistency (reliability) and accuracy (validity) of the data derived from them -- may or may not be less stringent for some purposes than for others, for example, for quality improvement but not evaluative purposes. As fidelity measurement – including the measurement of therapist adherence -- moves from the realm of efficacy research to effectiveness and implementation research, and ultimately into implementation monitoring systems used in practice (Aarons et al., 2011), it will be important to develop evidence for the feasible, reliable, and valid use of adherence instruments for particular purposes – that is, to make specific types of decisions about therapist adherence – in practice contexts.





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Table 1: Clinical contexts in which adherence measurement methods were used (n = 249)


1Clinical Contextual Variables

n of measurement methods

% of methods used with contextual variable

Treatment Models Assessed by Adherence Measurement Methods

Cognitive Behavioral

147

59.0%

Motivational Interviewing

38

15.3%

Family Therapy

36

14.5%

Interpersonal Psychotherapy

35

14.1%

Parent Training

33

13.3%

Psychodynamic/Psychoanalytic

25

10.0%

Clinical Problems Assessed

Substance Use

71

28.5%

Anxiety (w/out PTSD)

68

27.3%

Mood Disorders

57

22.9%

Disruptive Behavior Problems & Delinquency

37

14.9%

Eating Disorders

18

7.2%

PTSD

13

5.2%

Psychoses

11

<5%

Personality

4

<5%

ADHD

4

<5%

Autism Spectrum Disorders

2

<5%

Client Characteristics

Client Age

Adults

127

51.0%

Children only

99

39.8%

Both Adults and Children

6

2.4%

Client Gender

Males & Females

194

77.9%

Males only

18

7.2%

Females only

9

3.6%

Client Race/Ethnicity

Caucasian

142

57%

African American

89

35.7%

Latino/Hispanic

41

16.5%

Native American

24

9.6%

Multi-Ethnic

18

7.2%

Other

68

27.3%

Treatment Settings

Clinic Setting

137

55%

Academic Clinics

64

25.7%

Community Clinics

56

22.5%

VA Clinics

3

1.2%

Could not be determined

48

19.3%

Schools

17

6.8%

Community setting –unable to specify

25

10%

Treatment Provider Characteristics

Provider Degree

PhD/MD

131

52.6%

PhD Students

54

21.7%

Master’s degree

94

37.8%

Bachelor’s degree

39

15.7%

High School diploma

13

5.2%

Provider Discipline

Psychology

136

54.6%

Social Work

50

20.1%

Psychiatry

40

16.1%

Counseling

19

7.6%

Education

6

2.4%

Marital &Family Therapy

2

.8%

Percentages within categories often total more than 100% since one adherence measurement method may be used in multiple clinical contexts within and across studies.

Table 2: Measurement Method Characteristics


Measurement Method Characteristics

n of measurement methods

% of methods

Type of Measurement Method (n =249)

Observational

178

71.5%

Written

65

26.1%

Psychometric Evaluation

Results reported

185

74.3%

Psychometric properties reported

87

35%

Reliability evidence provided







Intraclass Correlations

43

17.3

Kendall’s Coefficient of Concordance

3

1.2%

Cronbach’s alpha provided

19

7.6%

Cohen’s Kappa

13

5.2%

Validity evidence







Convergence, concurrent, or discriminant

6 - 11

2.4 – 4.4%

Association of adherence with outcomes

26

10.4%

Details of Observational Data Collection (n = 178)

Audio recording

100

56.2%

Video recording

73

41%

Live observation

5

2.8%

Treatment Session Sampling Strategy

Not reported

94

52.8%

Proportion of treatment sessions coded

140

78.7%

20 – 25% of sessions

23

27%

Entire session coded

144

80%

Session segments coded

11

6.2%

Coding Personnel

Clinicians

57

22.9%

University students or research assistants

67

26.9%

Study authors or treatment experts

51

20.5%

Details of Written Data Collection (n=65)

Treatment Session Sampling Strategy

All sessions

43

66.2%

Once weekly

6

9.2%

Once monthly

4

6.2%

Respondents

Therapists

56

86.2%

Clients

11

16.9%


Percentages within categories often total more than 100% since one adherence measurement method may be used in multiple clinical contexts within and across studies.





Figure 1. Flow of Selection and Retention for Review of Published Articles

All potential articles from Medline and PsychInfo

(n = 750)


Articles that met screening criteria (n= 397)


Construct assessed in article was not therapist adherence

(n = 41)

N41

Duplicates

(n = 15)


Total articles included in review


(n= 341)



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