Fidelity Assessment of the Multiple Family Group Intervention for Disruptive Behavioral Disorders Among Children and Adolescents in Uganda.

Background: Globally, one in seven 10-19-year-olds experiences a mental disorder, accounting for 13% of the global burden of disease in this age group. In low- and middle-income countries (LMICs), many children and adolescents face serious mental health disorders, including disruptive behavioral disorders (DBDs), which often begin in childhood and adolescence. Between 2016 and 2021, a large cluster randomized controlled trial was conducted in Uganda under the SMART Africa initiative to examine the impact and implementation of the Multiple Family Group (MFG) intervention for children with behavioral problems and their families. The intervention proved efficacious in reducing impaired functioning and had the potential to improve family dynamics, whether delivered by community members or parents. With limited mental health experts in Uganda, understanding the fidelity of this mental health intervention with task shifting will be critical. Objective: This study systematically assesses the fidelity of the MFG intervention, focusing on the dose dimension, which includes the frequency and duration of intervention sessions and adherence to the intervention manual. Methods: The fidelity assessment was embedded within the SMART Africa trial and conducted after every MFG session for facilitators and caregivers and at 25% of the sessions (sessions 4, 8, 12, and 16) by research staff. Facilitators and participants completed a 5-minute fidelity assessment checklist at the end of each session, while independent fidelity observations were conducted for 25% of the sessions by trained research assistants. Data were analyzed to assess the relationship between planned and actual implementation. Results: In this study, the MFG intervention included 1,290 participants and caregivers, with children having an average age of 12 years and most caregivers being female with a primary education. Each session had an average attendance of over 70%, with 33% of participants attending all 15 sessions and 77.4% attending at least 11 sessions, indicating good adherence. Participants completed 16,470 fidelity assessment surveys, showing excellent coverage of intervention content (95%-100%), which improved over time. Research assistants reported high fidelity, with 567 assessments showing 93%-98% coverage. Facilitators filled out 2,189 surveys, with a mean session component coverage of 98.6%. Conclusion: The fidelity assessment indicates that the MFG intervention was well-delivered in Uganda. High adherence and positive feedback affirm the intervention's successful implementation and support for task shifting mental health interventions while maintaining high fidelity in countries with limited mental health experts.