Developing a checklist to assess fidelity of training and treatment delivery of 11 for Health, a football-based health education intervention for youth.

BackgroundThe NHS Diabetes Prevention Programme (NHS-DPP) has been delivered by four commercial organizations across England, to prevent people with impaired glucose tolerance developing Type 2 diabetes. Evidence reviews underpinning the NHS-DPP design specification identified 19 Behavior Change Techniques (BCTs) that are the intervention “active ingredients.” It is important to understand the discrepancies between BCTs specified in design and BCTs actually delivered.PurposeTo compare observed fidelity of delivery of BCTs that were delivered to (a) the NHS-DPP design specification, and (b) the programme manuals of four provider organizations.MethodsAudio-recordings were made of complete delivery of NHS-DPP courses at eight diverse sites (two courses per provider organization). The eight courses consisted of 111 group sessions, with 409 patients and 35 facilitators. BCT Taxonomy v1 was used to reliably code the contents of NHS-DPP design specification documents, programme manuals for each provider organization, and observed NHS-DPP group sessions.ResultsThe NHS-DPP design specification indicated 19 BCTs that should be delivered, whereas only seven (37%) were delivered during the programme in all eight courses. By contrast, between 70% and 89% of BCTs specified in programme manuals were delivered. There was substantial under-delivery of BCTs that were designed to improve self-regulation of behavior, for example, those involving problem solving and self-monitoring of behavior.ConclusionsA lack of fidelity in delivery to the underlying evidence base was apparent, due to poor translation of design specification to programme manuals. By contrast, the fidelity of delivery to the programme manuals was relatively good. Future commissioning should focus on ensuring the evidence base is more accurately translated into the programme manual contents.

BackgroundNon-specific low back pain (LBP) commonly presents to primary care, where inappropriate use of imaging remains common despite guideline recommendations against its routine use. Little is known about strategies to enhance intervention fidelity (i.e., whether interventions were implemented as intended) for interventions developed to reduce non-indicated imaging for LBP.ObjectivesWe aim to inform the development of an intervention to reduce non-indicated imaging among general practitioners (GPs) and chiropractors in Newfoundland and Labrador (NL), Canada. The study objectives are: [1] To explore perceived barriers and enablers to enhancing fidelity of training of GPs and chiropractors to deliver a proposed intervention to reduce non-indicated imaging for LBP and [2] To explore perceived barriers and enablers to enhancing fidelity of delivery of the proposed intervention.MethodsAn exploratory, qualitative study was conducted with GPs and chiropractors in NL. The interview guide was informed by the National Institutes of Health Behavior Change Consortium fidelity checklist; data analysis was guided by the Theoretical Domains Framework (TDF). Participant quotes were coded into TDF domains, belief statements were generated at each domain, and domains relevant to enhancing fidelity of provider training or intervention delivery were identified.ResultsThe study included five GPs and five chiropractors from urban and rural settings. Barriers and enablers to enhancing fidelity to provider training related to seven TDF domains: [1] Beliefs about capabilities, [2] Optimism, [3] Reinforcement, [4] Memory, attention, and decision processes, [5] Environmental context and resources, [6] Emotion, and [7] Behavioural regulation. Barriers and enablers to enhancing fidelity to intervention delivery related to seven TDF domains: [1] Beliefs about capabilities, [2] Optimism, [3] Goals, [4] Memory, attention, and decision processes, [5] Environmental context and resources, [6] Social influences, and [7] Behavioural regulation.ConclusionThe largest perceived barrier to attending training was time; perceived enablers were incentives and flexible training. Patient pressure, time, and established habits were perceived barriers to delivering the intervention as intended. Participants suggested enhancement strategies to improve their ability to deliver the intervention as intended, including reminders and check-ins with researchers. Most participants perceived intervention fidelity as important. These results may aid in the development of a more feasible and pragmatic intervention to reduce non-indicated imaging for GPs and chiropractors in NL.

To investigate the reliability of a measure of fidelity of therapist delivery, quantify fidelity of delivery, and determine factors impacting fidelity in the Rehabilitation EArly for Congenital Hemiplegia (REACH) clinical trial. Ninety-five infants (aged 3-9 months) with unilateral cerebral palsy participated in the REACH clinical trial. The Therapist Fidelity Checklist (TFC) evaluated key intervention components. Video-recorded intervention sessions were scored using the TFC. Inter- and intrarater reliability was percentage agreement 77% to 100%. Fidelity of delivery was high for 88.9% of sessions and moderate for 11.1% of sessions. Sessions with moderate scores included infants receiving infant-friendly bimanual therapy and occurred at the intervention midpoint or later. No significant relationships were found for TFC scores and infant age, manual ability, or parent engagement. Fidelity of delivery was high for the REACH trial in most intervention sessions. Standardized therapist training with intervention manuals and monthly peer-to-peer support likely contributed to these results.

BackgroundFidelity assessment of behaviour change interventions is vital to understanding trial outcomes. This study assesses the delivery fidelity of behaviour change techniques used in the Retirement in ACTion (REACT) randomised controlled trial. REACT is a community-based physical activity (PA) and behaviour maintenance intervention to prevent decline of physical functioning in older adults (≥ 65 years) at high risk of mobility-related disability in the UK.MethodsThe delivery fidelity of intervention behaviour change techniques and delivery processes were assessed using multi-observer coding of purposively sampled in-vivo audio recordings (n = 25) of health behaviour maintenance sessions over 12-months. Delivery fidelity was scored using a modified Dreyfus scale (scores 0–5) to assess competence and completeness of delivery for each technique and delivery process. “Competent delivery” was defined as a score of 3 points or more for each item. Examples of competent intervention delivery were identified to inform recommendations for future programme delivery and training.ResultsThe mean intervention fidelity score was 2.5 (SD 0.45) with delivery fidelity varying between techniques/processes and intervention groups. Person-centred delivery, Facilitating Enjoyment and Promoting Autonomy were delivered competently (scoring 3.0 or more). There was scope for improvement (score 2.0—2.9) in Monitoring Progress (Acknowledging and Reviewing), Self-Monitoring, Monitoring Progress (Eliciting Benefits of Physical Activity), Goal Setting and Action Planning, Modelling, Supporting Self-Efficacy for Physical Activity and Supporting Relatedness. Managing Setbacks and Problem Solving was delivered with low fidelity. Numerous examples of both good and sub-optimal practice were identified.ConclusionsThis study highlights successes and improvements needed to enhance delivery fidelity in future implementation of the behavioural maintenance programme of the REACT intervention. Future training of REACT session leaders and assessment of delivery fidelity needs to focus on the delivery of Goal setting and Action Planning, Modelling, Supporting Relatedness, Supporting Self-Efficacy for Physical Activity, and Managing Setbacks/ Problem Solving.

This study was part of a process evaluation for a single-blind, randomized controlled pilot study comparing Better Conversations with Primary Progressive Aphasia (BCPPA), an approach to communication partner training, with no speech and language therapy treatment. It was necessary to explore fidelity of delivery (delivery of intervention components) and intervention enactment (participants' use of intervention skills in the form of conversation behaviours comprising facilitators, that enhance the conversational flow, and barriers, that impeded the flow of conversation). This study aimed to: (1) Outline an adapted methodological process that uses video observation, to measure both fidelity of delivery and enactment. (2) Measure the extent to which the BCPPA pilot study was delivered as planned, and enacted. Observational methods were used alongside statistical analysis to explore the fidelity of intervention and enactment using video recordings obtained from the BCPPA pilot study. A 5-step methodology, was developed to measure fidelity of delivery and enactment for the BCPPA study using video-recorded data. To identify delivery of intervention components, a random sample of eight video recorded and transcribed BCPPA intervention sessions was coded. To examine the enactment of conversation behaviours, 108 transcribed 10 -min-video recorded conversations were coded from 18 participants across the control and intervention group. Checklists and guidelines for measurement of fidelity of treatment delivery and coding spreadsheets and guidelines for measurement of enactment are presented. Local collaborators demonstrated 87.2% fidelity to the BCPPA protocol. Participants in the BCPPA treatment group increased their use of facilitator behaviours enacted in conversation from a mean of 13.5 pre-intervention to 14.2 post-intervention, whilst control group facilitators decreased from a mean of 15.5 to 14.4, over the same timescale. This study proposes a novel and robust methods, using video recorded intervention sessions and conversation samples, to measure both fidelity of intervention delivery and enactment. The learnings from this intervention are transferable to other communication interventions.

BackgroundEnsuring reduction in transmission of lymphatic Filariasis (LF) and addressing the compliance of people to mass drug administration (MDA) has led to renewed efforts in the field. School-based health education (SBHE) intervention, considered a cost-effective strategy with potential to reach the wider public through young people, was adopted as a strategy for social mobilization. This study assessed SBHE perceptions, implementation barriers, and factors in the supporting environment as well as its efficiency to successfully change LF MDA-related knowledge and practice.MethodsThis mixed methods study was conducted in four sites of Lalitpur district, Nepal. Classroom-based interactive health education sessions were used as the main intervention strategy in the study. In total, 572 students were assigned to intervention and control groups. Questionnaires were distributed before and after the intervention. Mann-Whitney and McNemar tests were used for analysis. Focus-group discussions with teachers and students and in-depth interviews with the district LF program manager as well as Education Office and school management authorities were conducted. Qualitative thematic analysis approach was adopted.ResultsIntervention curriculum played a significant role in increasing children’s knowledge and practice (p<0.001). Barriers for school-based interventions were budget constraints, human resource deficiencies, lack of opportunities to conduct practical classes under the curriculum, and lack of collaboration with parents. Supportive factors were training provision, monitoring and evaluation practice, adequate facilities and equipment, positive parental attitudes, presence of interested teachers and students, and prioritization by program implementers.ConclusionEffective program planning practices such as proper fiscal management, human resource management, training mechanisms, and efforts to promote practical classes and coordination with parents are required to develop and institutionalize the intervention. Effective learning and a supportive school environment appear to be important components to support implementation. The SBHE intervention is a feasible and promising intervention for accelerating compliance towards MDA to eliminate LF.

Background Many people with early rheumatoid arthritis (RA) report foot pain and walking disability. Self-reported walking disability two years post-diagnosis is the main predictor of persistent disability. A psychologically informed gait rehabilitation intervention (Great Strides) for early RA was developed to address this, consisting of two compulsory sessions and up to four optional sessions delivered over three months. Physiotherapists and podiatrists received bespoke training to deliver Great Strides, incorporating motivational interviewing (MI) and behaviour change techniques (BCTs), to help patients to complete their walking exercises at home. The aim of this study was to assess fidelity of delivery within the Gait Rehabilitation in Early Arthritis Trial (GREAT) feasibility study. Methods Four physiotherapists and two podiatrists delivered 78 Great Strides sessions across three centres in the UK. All sessions were audio recorded and double coded. The Motivational Interviewing Treatment Integrity (MITI) Rating Scale (scoring ≥4 represents good proficiency) and tailored treatment fidelity measures of the six core elements and 17 BCTs delivered in session 1, five core elements delivered in session 2, and 12 BCTs in session 2-6, were developed to examine fidelity of delivery. Two trained, independent assessors rated audio recordings of Great Strides and assessed the extent to which core elements, aspects of MI and BCTs were delivered across sessions. Results Data from 28 (80%) adult participants across a total of 64 sessions were rated for core components and BCTs and 37 (50%) of sessions were analysed for MI. Relational (score=4.4) and technical (score=4.2) aspects of MI were delivered with good fidelity across the whole sample. The 6 core elements and 7 BCTs in Session 1 were conveyed with high (over 80%) treatment fidelity, but 10 further BCTs were not consistently delivered (range 23-69%). In session 2, the 5 core elements and 3 BCTs were provided with high fidelity, but another 9 BCTs were not reliably delivered (range 11-56%). Sessions 3 and 4 reliably delivered 3 out of 12 BCTs and only one session 5 and 6 was delivered. Inter-rater reliability showed agreement of over 80% was reached between raters for all sessions (range 82-87%). Conclusion Physiotherapists and podiatrists were able to deliver the core elements of GREAT sessions with high fidelity and fidelity assessment methods were appropriate. Results showed a maximum of 4 sessions was sufficient. However, treatment fidelity might be enhanced with further training or greater on-going support, as findings suggested clinicians (physiotherapists) with previous MI experience were more proficient at offering key elements of MI. Additionally, the Great Strides intervention could be amended to improve delivery, as research shows complex interventions should consider mandatory BCTs alongside optional ones, depending on the needs of individual participants. Disclosures E. Godfrey None. M. Sekhon None. G. Hendry None. N.E. Foster None. S. Hider None. M. van der Leeden None. H. Mason None. A. McConnachie None. I. McInnes None. A. Patience None. C. Sackley None. M. Steultjens None. A. Williams None. J. Woodburn None. L. Bearne None.

BackgroundMaking Every Contact Count (MECC) is a public health strategy which strives to enable brief interventions to be implemented through opportunistic healthy lifestyle conversations. In a mental health inpatient setting a bespoke MECC training package has been developed to encourage cascade training through a train the trainer model and to incorporate an additional regional health strategy A Weight Off Your Mind into Core MECC training to provide a focus on healthy weight management. This study evaluated the fidelity of design of MECC in the mental health inpatient setting and fidelity of the training package currently being cascaded across the region.MethodsInitially a documentary analysis of six documents shared through the mental health inpatient setting including MECC implementation guide, logic model, checklist and evaluation framework. Documents were analysed using the Template for Intervention Description and Replication (TIDieR) checklist and coded using the Behaviour Change Technique (BCT) Taxonomy version one (BCTTv1) and the Expert Recommendations for Implementing Change (ERIC) Taxonomy. Coding was compared against MECC guidance documents to complete the fidelity assessment. A training delivery guide, training slides and two recordings of both train the trainer and Core MECC + A Weight Off Your Mind training were analysed for behaviour change techniques (BCTs) and compared to conduct a fidelity training assessment.ResultsOverall the implementation of MECC in the mental health inpatient setting had moderate fidelity to the MECC guidance, with a total of 31 BCTs identified across guidance and provider documents and a 77% adherence of provider documents to guidance. The highest level of fidelity applied to the MECC implementation guide where 86% of identified BCTs were also present. The training package showed high fidelity that both training programmes were being delivered as intended with 100% of BCT matched from training materials to training transcripts. Potential loss of fidelity through additional BCTs was present across provider documents and training transcripts.ConclusionThe implementation of MECC across the mental health inpatient setting and the training package appear to be delivered as intended therefore demonstrating good fidelity and potential benefits to public health. Future research would benefit from assessing cascade training sessions from those who have completed train the trainer to evaluate ongoing fidelity of training across the trust.

The negative impact of soil-transmitted helminths (STHs) in Nigeria is enormous, and it poses serious public health issues and concerns. This study was undertaken to investigate the impact of health education intervention on reinfection of STHs in pupils of rural schools of Kogi East, North Central Nigeria. A total of 10 schools with the highest prevalence of STHs at baseline were selected from the 45 schools assessed during the baseline survey. These 10 schools were randomly paired into two groups of 5 schools per group. Five schools were dewormed and given health education (DHE) intervention while the other 5 schools were dewormed only (DO) without health education. Reassessment of schools for reinfection was carried out for a period of 12 months. Data obtained were analyzed using descriptive statistics. Student's t-test was used to make comparison between interventions in the incidence of infections. Analysis was carried out at p < 0.05. Reinfection with STHs was observed from the 28th week (7th month) of both interventions with incidence of 0.29 (2 pupils) and 1.00 (7 pupils) in DO and DHE schools, respectively. In the 36th week (9th month), incidence observed in schools given DHE was 0.56 (5 pupils) while incidence of 0.89 (8 pupils) was observed in DO schools, and there was no significant difference (t = −1.000, p = 0.347) between the interventions. At 48th week (12th month), there was no significant difference (t = −0.547, p = 0.599) in incidence between the DHE and DO schools with incidence of 1.00 (12 pupils) and 0.83 (10 pupils), respectively. Hookworms had an incidence of 0.78 (7 pupils) at DHE schools and 0.56 (5 pupils) at DO schools in the 36th week while an incidence of 0.92 (11 pupils) and 0.83 (10 pupils) at DHE and DO schools, respectively, in the 48th week. Ascaris lumbricoides was only observed in DHE schools in a pupil with an incidence of 0.11 (1 pupil) and 0.08 (1 pupil) at 36th and 48th weeks. There was no significant difference in the prevalence of the parasites between DO and DHE intervention groups (p > 0.05). School-based health education intervention had no significant impact on STH incidence in pupils of rural schools in Kogi East. Community-based deworming should be encouraged alongside improvement in the water, sanitation, and hygiene infrastructures and practices at both school and home.

Behavioral support for smoking cessation is delivered through different modalities, often guided by treatment manuals. Recently developed methods for assessing fidelity of delivery have shown that face-to-face behavioral support is often not delivered as specified in the service treatment manual. This study aimed to extend this method to evaluate fidelity of telephone-delivered behavioral support. A treatment manual and transcripts of 75 audio-recorded behavioral support sessions were obtained from the United Kingdom's national Quitline service and coded into component behavior change techniques (BCTs) using a taxonomy of 45 smoking cessation BCTs. Interrater reliability was assessed using percentage agreement. Fidelity was assessed by comparing the number of BCTs identified in the manual with those delivered in telephone sessions by 4 counselors. Fidelity was assessed according to session type, duration, counselor, and BCT. Differences between self-reported and actual BCT use were examined. Average coding reliability was high (81%). On average, 41.8% of manual-specified BCTs were delivered per session (SD = 16.2), with fidelity varying by counselor from 32% to 49%. Fidelity was highest in pre-quit sessions (46%) and for BCT "give options for additional support" (95%). Fidelity was lowest for quit-day sessions (35%) and BCT "set graded tasks" (0%). Session duration was positively correlated with fidelity (r = .585; p < .01). Significantly fewer BCTs were used than were reported as being used, t(15) = -5.52, p < .001. The content of telephone-delivered behavioral support can be reliably coded in terms of BCTs. This can be used to assess fidelity to treatment manuals and to in turn identify training needs. The observed low fidelity underlines the need to establish routine procedures for monitoring delivery of behavioral support.

BackgroundThe National Health Service Diabetes Prevention Programme (NHS-DPP) is a behavioural intervention for people identified as high risk for developing type 2 diabetes that has been rolled out across England. The present study evaluates whether the four commercial providers of the NHS-DPP train staff to deliver behaviour change technique (BCT) content with fidelity to intervention plans.MethodOne set of mandatory training courses across the four NHS-DPP providers (seven courses across 13 days) was audio-recorded, and all additional training materials used were collected. Recordings and training materials were coded for BCT content using the BCT Taxonomy v1. BCTs and depth of training (e.g. instruction, demonstration, practice) of BCT content was checked against providers’ intervention plans.ResultsTen trainers and 78 trainees were observed, and 12 documents examined. The number of unique BCTs in audio recordings and associated training materials ranged from 19 to 44 across providers, and staff were trained in 53 unique BCTs across the whole NHS-DPP. Staff were trained in 66% of BCTs that were in intervention plans, though two providers trained staff in approximately half of BCTs to be delivered. The most common way that staff were trained in BCT delivery was through instruction. Training delivery style (e.g. experiential versus educational) varied between providers.ConclusionObserved training evidences dilution from providers’ intervention plans. NHS-DPP providers should review their training to ensure staff are trained in all key intervention components, ensuring thorough training of BCTs (e.g. demonstrating and practicing how to deliver) to enhance BCT delivery.

The benefits of pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) are restricted by poor uptake and completion. Lay health workers (LHWs) have been effective in improving access to treatment and services for other health conditions. We have successfully shown the feasibility of this approach in a PR setting and its acceptability to the LHWs and COPD patients. We present here the feasibility of assessment, and the fidelity of delivery of LHW support achieved for COPD patients referred for PR. LHWs, volunteer COPD patients experienced in PR, received training in the intervention including communication skills, confidentiality and behaviour change techniques (BCTs). Interactions between LHWs and patients were recorded, transcribed and coded for delivery style and BCTs. Inter-rater agreement on the coding of delivery style and BCTs was high at >84%. LHWs built rapport and communicated attentively in over 80% of interactions. LHWs most consistently delivered BCTs concerning information provision about the consequences of PR often making those consequences salient by referring to their own positive experience of PR. Social support BCTs were also used by the majority of LHWs. The use of BCTs varied between LHWs. The assessment of intervention delivery fidelity by LHWs was feasible. LHW training in the setting of PR should add emphasis to the acquisition of BCT skills relating to goal setting and action planning.

NHS England commissioned independent service providers to deliver the NHS Low-Calorie Diet Programme pilot. Previous research has illustrated a drift in the fidelity of behaviour change techniques (BCTs) during the delivery of the programme provided through face-to-face group or one-to-one behavioural support. The aim of this study was to assess the delivery fidelity of the BCT content in the digital delivery of the programme. Online, app chat and phone call support content was coded using The Behaviour Change Technique Taxonomy. BCTs delivered by each service provider (N = 2) were calculated and compared to the BCTs specified in the NHS service specification and those specified in the providers' programme plans. Between 78% and 83% of the BCTs identified in the NHS service specification were delivered by the service providers. The fidelity of BCT delivery to those specified in providers' programme plans was 60%-65% for provider A, and 82% for provider B. The BCT content of the digital model used in the NHS-LCD programme adhered well to the NHS service specification and providers' plans. It surpassed what has been previously observed in face-to-face services provided through group or one-on-one behavioural support models.

Tertiary Individual Prevention is an interprofessional inpatient rehabilitation programme offered to workers affected by work-related skin diseases. Health educational interventions aiming at changing skin protection behaviour are a pivotal component of the programme. This paper aims at characterizing the content of the educational interventions of the interprofessional inpatient rehabilitation programme and at reporting the mechanisms and functions for behaviour change. We retrospectively analysed existing health educational interventions with document analyses and field observations. The intervention was described using the Template of Intervention Description and Replication (TIDieR). For the intervention content, the Behaviour Change Technique (BCT) Taxonomy (v1) was applied. To characterize the intervention in detail, the BCTs were then mapped to the intervention functions, the COM-B model (Capability, Opportunity, Motivation) and the Theoretical Domains Framework (TDF) from the Behaviour Change Wheel (BCW). The health educational interventions consist of seven components. Five are delivered in a group and two as tailored face-to-face counselling. We identified 23 BCTs in 10 groups. The most common used BCTs are "instruction on how to perform skin protection behaviour," "salience of consequences," "information about skin health," and "demonstration of skin protection behaviour." To initiate the process of behaviour change in skin protection behaviour by the individuals, changes are required in all three behavioural sources (Capability, Opportunity, Motivation) and primarily in the theoretical constructs "behavioural regulation," "skills," and "beliefs about consequences." For this purpose, the five intervention functions "enablement," "training," "education," "modelling," and "persuasion" are used. Health educational interventions to change skin protection behaviour consists of different BCTs, mechanisms of change and intervention functions. This work helps to better understand the mechanisms and means of behaviour change and enables replication in other settings. In the future, the intervention programme should be extended to include BCTs addressing domains for behaviour changes which have not yet been included to maintain the new behaviour in the long-term. Finally, we recommend to report more elements of the rehabilitation programme (e.g. psychological interventions) in a standardized manner by frameworks used in this paper.

Background/Aims:Self-management interventions are increasingly being developed and researchedto improve long-term condition outcomes. To understand and interpretfindings, it is essential that fidelity of intervention delivery andparticipant engagement are measured and reported. Before developing fidelitychecklists to assess treatment fidelity of interventions, currentrecommendations suggest that a synthesis of fidelity measures reported inthe literature is completed. Therefore, here we aim to identify what thecurrent measures of fidelity of intervention delivery and engagement forself-management interventions for long-term conditions are and whether thereis treatment fidelity.Methods:Four databases (MEDLINE, PubMed, CINAHL Plus and ScienceDirect) and thejournal implementation science were systematically searched to identifypublished reports from inception to December 2020 for experimental studiesmeasuring fidelity of intervention delivery and/or participant engagement inself-management interventions for long-term conditions. Data on fidelity ofdelivery and engagement measures and the findings were extracted andsynthesised.Results:Thirty-nine articles were identified as eligible, with 25 studies measuringfidelity of delivery, 19 reporting engagement and 5 measuring both. Forfidelity of delivery, measures included structured checklists, participantcompleted measures and researcher observations/notes. These were completedby researchers, participants and intervention leaders. Often there waslittle information around the development of these measures, particularlywhen the measure had been developed by the researchers, rather than buildingon others work. Eighteen of 25 studies reported there was fidelity ofintervention delivery. For engagement, measures included data analytics,participant completed measures and researcher observations. Ten out of 19studies reported participants were engaged with the intervention.Conclusion:In complex self-management interventions, it is essential to assess whethertreatment fidelity of each core component of interventions is delivered, asoutlined in the protocol, to understand which components are having aneffect. Treatment fidelity checklists comparing what was planned to bedelivered, with what was delivered should be developed with pre-definedcut-offs for when fidelity has been achieved. Similarly, when measuringengagement, while data analytics continue to rise with the increase indigital interventions, clear cut-offs for participant use and contentengaged with to be considered an engagement participant need to bepre-determined.