Wellbeing The Five Essential Elements Epub File
Montez Savoie
"Wellbeing is about the combination of our love for what we do each day, the quality of our relationships, the security of our finances, the vibrancy of our physical health and the pride we take in what we have contributed to our communities. Most importantly, it's about how these five elements interact."
We (a) describe the difficulties of, and propose a method for, identifying the essential elements of a contextualised intervention; (b) provide a worked example of an approach for critiquing the validity of putative essential elements; and (c) demonstrate how essential elements can be refined during a trial without compromising the fidelity assessment.
The concept of assessing fidelity as part of intervention evaluation originates from psychotherapeutic programs. The aim of fidelity assessment in this context is to ensure prescribed treatments are delivered with minimal variation [15, 21] and adhere to the behaviour-change theory that informed their design. This approach has proliferated within implementation science and is now used for a range of interventions designed to change professional practice in health care. There is increasing formalisation of the theory that underpins these interventions and their essential elements, leading to testable theoretical frameworks and taxonomies of standardised techniques that support replicability and evidence synthesis across studies, e.g. [29, 30].
When based on previous studies, intervention designers can identify essential elements from analysis of earlier interventions or operationalise them using exemplary models that have established effectiveness [9, 10, 12]. Theoretically informed standardised behaviour-change techniques are in development, but these are currently limited to interventions founded on psychological theories [30]. When designing and evaluating novel contextualised interventions, designers can either articulate the essential elements themselves or consult with expert colleagues [8, 9, 19, 56]. Many evaluations tackle this post hoc, piecing together the essential elements via discussion with the designers and/or by reviewing intervention materials [12, 19, 55].
The degree to which essential elements are specified must align with the level of flexibility in the intervention design. Minimally specified essential elements are appropriate for highly flexible interventions because they can be interpreted for different contexts [34, 60, 61]. These essential elements tend to be expressed as principles, goals or functions (rather than specific techniques or formats) as these provide scope for diverse implementation strategies. Fidelity rests on the extent to which the resulting strategies align with the principles, goals and/or functions (see [59] for examples) [33, 62]. Equal emphasis should be placed on how discretionary elements were tailored and with what process effects [33, 59].
Where the intervention combines standardised and flexible components, an appropriate balance must be found. Essential elements that are too tightly specified oblige providers to adhere to prescriptive scripts and techniques which may be suboptimal or entirely inappropriate in different contexts and circumstances [27, 35, 62], whereas minimally specified essential elements may not provide sufficient concrete guidance for developing or monitoring the core intervention activities [21]. The specificity of essential elements is critical for defining what the intervention is and what it is not, including which elements are genuinely essential and which can be adapted [13, 55]. To date, the literature does not provide the detail needed to identify, or determine the specificity of, essential elements for contextualised interventions.
Specifically we (a) describe the challenges of, and propose a method for, identifying the essential elements of a contextualised intervention (a semi-flexible, theoretically eclectic intervention designed for complex settings); (b) provide a worked example of an approach for critiquing the validity of putative essential elements; and (c) demonstrate how essential elements can be refined during a trial without compromising the fidelity assessment. We consider how this approach might complement current methods for identifying essential elements.
The manner in which the essential elements should be articulated was complicated by the paradigmatic tensions and different fidelity traditions in the composite theory. For example, cognitive behavioural theories lean towards positivism and experimental intervention approaches and fall within the standardised approach to fidelity assessment outlined at the beginning of this paper in which essential elements are tightly specified. Systems thinking, on the other hand, proposes a complexity-orientated ecological worldview in which interventions are loosely specified for local adaptation and essential elements are articulated as principles rather than concrete techniques. SPIRIT, like many contemporary interventions, was occupying a middle ground.
Flexibility. The expression of the essential elements needed to accommodate three levels of flexibility: (a) agencies were able to select different session options from a menu of components, (b) they could tailor the topics and goals of these options to address local priorities, and (c) expert providers determined the detail of delivery (see Table 1). We could not foresee how these decisions would shape the content and form of the intervention. Given that meaningful comparison of the extent to which essential elements were delivered required that they be equally applicable across all intervention sites, our fidelity criteria had to cover both standardised and locally adapted intervention components and reconcile potentially disparate adaptions.
As a result of these uncertainties, we were unable to predetermine the content, scope and specificity of the essential elements. Consequently, we judged it necessary to identify provisional essential elements and observe them in the field, using empirical evidence from the process evaluation to revise them as required. Our goal was to critique the construct validity of the essential elements [9] and modify them while simultaneously using them as reliable fidelity indicators.
The research group (which comprised the intervention designers, implementation team and process evaluation team working in parallel) used the relatively lengthy intervention period as an opportunity to identify, assess and refine hypothesised essential elements during the trial. This was aided by the multi-agency, stepped wedge design of the trial which allowed us to monitor the entire intervention in some agencies and still have scope to trial revisions in other agencies. A modified version of this approach could be applied to other trial designs.
These results overlap with our methods in that we show how process evaluation data collection and analysis was used to critique essential elements. This detail is provided so that the procedure we devised is transparent and replicable.
The approach we devised was to identify potential essential elements inductively. As each session outline became available, the process evaluation team asked three questions. (a) What do the session goals and the planned characteristics of the session tell us about which change principles this session is attempting to utilise? (b) Which of these are likely to be essential to the effectiveness of the session? (c) What would these change principles look like in delivery (how can we operationalise them so that can be measured or fully described?)? This produced a list of draft essential elements that we further developed with the SPIRIT designers to accurately describe the elements they believed were essential for that session to be effective. These potential essential elements included session content, key messages, provider characteristics, presentation techniques, activities, and particular attendees and types of participation. At this stage, we consciously trialled many essential elements that we suspected would be collapsed or discarded later. See Additional file 1 for an example.
Detailed notes were made about the nature of the problem, what interactions affected it (where this was appropriate) and possible solutions that took account of our growing appreciation of contextual constraints and opportunities. Notes included suggestions about where session-specific essential elements could be collapsed and rephrased so that they could be applied across all agencies and intervention components.
In this stage, we used the likely essential elements in our fidelity assessment data collection and continued using the methods described in stage 2 to collate information about the extent to which they were delivered and to explore their functionality and congruence with the program theory.
Not all fidelity criteria can be assessed in the same manner [9]. Structural items such as participant attendance and the number, type and duration of sessions are easily observed and can usually be captured numerically. However, process items (which may be more significant in terms of intervention effects [9]) such as presentation styles, types of participation and overall quality tend to be more descriptive and usually require context-sensitive qualitative assessment, especially direct observation [9, 19, 62]. Most of our essential elements were processual so we found that their inclusion in the fidelity assessment required that they be monitored not only in terms of whether they were delivered, but the extent to which they were delivered and how this was done. Our aim was to devise a pragmatic method of standardising observations across sites that could accommodate local adaptation and extensive data collection.
Third, we concluded that we had been unsuccessful in finding semi-objective generalisable ways of scoring certain quality concepts (e.g. Was the presentation engaging? Was the content relevant?). We decided to rely entirely on participant feedback to score these essential elements. See Table 5 for an overview of the final scoring.
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