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“I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care

BACKGROUND: Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral...

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Autores principales: Mignogna, Joseph, Martin, Lindsey Ann, Harik, Juliette, Hundt, Natalie E., Kauth, Michael, Naik, Aanand D., Sorocco, Kristen, Benzer, Justin, Cully, Jeffrey
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2018
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5987469/
https://www.ncbi.nlm.nih.gov/pubmed/29866141
http://dx.doi.org/10.1186/s13012-018-0768-z
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author Mignogna, Joseph
Martin, Lindsey Ann
Harik, Juliette
Hundt, Natalie E.
Kauth, Michael
Naik, Aanand D.
Sorocco, Kristen
Benzer, Justin
Cully, Jeffrey
author_facet Mignogna, Joseph
Martin, Lindsey Ann
Harik, Juliette
Hundt, Natalie E.
Kauth, Michael
Naik, Aanand D.
Sorocco, Kristen
Benzer, Justin
Cully, Jeffrey
author_sort Mignogna, Joseph
collection PubMed
description BACKGROUND: Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol “fit” into their clinical practice. METHODS: A multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes. RESULTS: Providers described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients’ broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment). CONCLUSIONS: The therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the “fit” into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01149772 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s13012-018-0768-z) contains supplementary material, which is available to authorized users.
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spelling pubmed-59874692018-07-10 “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care Mignogna, Joseph Martin, Lindsey Ann Harik, Juliette Hundt, Natalie E. Kauth, Michael Naik, Aanand D. Sorocco, Kristen Benzer, Justin Cully, Jeffrey Implement Sci Research BACKGROUND: Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol “fit” into their clinical practice. METHODS: A multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes. RESULTS: Providers described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients’ broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment). CONCLUSIONS: The therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the “fit” into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01149772 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s13012-018-0768-z) contains supplementary material, which is available to authorized users. BioMed Central 2018-06-05 /pmc/articles/PMC5987469/ /pubmed/29866141 http://dx.doi.org/10.1186/s13012-018-0768-z Text en © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
spellingShingle Research
Mignogna, Joseph
Martin, Lindsey Ann
Harik, Juliette
Hundt, Natalie E.
Kauth, Michael
Naik, Aanand D.
Sorocco, Kristen
Benzer, Justin
Cully, Jeffrey
“I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care
title “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care
title_full “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care
title_fullStr “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care
title_full_unstemmed “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care
title_short “I had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care
title_sort “i had to somehow still be flexible”: exploring adaptations during implementation of brief cognitive behavioral therapy in primary care
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5987469/
https://www.ncbi.nlm.nih.gov/pubmed/29866141
http://dx.doi.org/10.1186/s13012-018-0768-z
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