Chapter 1 20 Impact of two implementation aspects: IMR fidelity and IMR completion Adequate dissemination and efficacy of research on EBPs for people with SMI require clear and precise specification of the quality of implementation (112-114). The relevance of fidelity lies in the assumption that “higher fidelity to an EBP predicts better outcomes for clients” (115). Fidelity is defined as the degree of adherence to the standards and principles of a program (112, 114). There are indications of this predictive validity of fidelity for some programs in the National EBPs Project in the United States (93), including ACT (116-120), IPS (121), and prior to our study (65) also for IMR (103, 122). Regarding the quality of implementation of IMR, not only fidelity, but also the level of exposure to IMR of participants (completion) appeared relevant to IMR efficacy (104, 106, 109). Completion refers to the level of IMR attendance (65) (Chapter 5). In addition to the percentage of participants exposed to >50% of the scheduled sessions, the total number of sessions attended appeared to be relevant. A minimum threshold of exposure to IMR may be required for treatment effects to occur (106). Before conducting the main study, we conducted a pilot study to explore the feasibility of a randomized controlled trial (97) (Chapter 2). This pilot study indicated that an RCT was feasible. However, the pilot study showed mixed results regarding the fidelity of the IMR implementation. The implementation of certain aspects of fidelity required further improvement. Moreover, the results indicated a 50% dropout rate from the treatment regimen (97). Based on the results of this pilot study and previous research, our main study explored the impact of fidelity and IMR completion rate on the efficacy of this intervention (Chapter 5). In the pilot study, the limitations of the IMR fidelity scale were revealed. Therefore, we added the IT-IS to the main study. Moreover, the study design was customized to facilitate completion analysis; a priori, we chose to assign more clients to the experimental condition (IMR) than the care as usual (CAU) group (76). In summary, although IMR appeared promising for implementation in the Netherlands, the inconsistent findings of previous studies indicated the need for further research on IMR efficacy and outcomes. The present study focused on two aspects of implementation that may have contributed to inconsistencies in the results of earlier RCTs: model fidelity and IMR completion.
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