The interest in examining the social validity of health interventions is resurging (Greenhalgh et al., 2016). Social validity reflects clients’ perceived acceptance of interventions (Kazdin, 2006). Two observations are driving the increasing attention to interventions’ acceptance. First is the realization that, in practice, acceptance contributes to clients’ pursuit and use of interventions. Clients will not seek, initiate, engage, and adhere to evidence‐based, effective interventions if they do not perceive the interventions favorably (Alessi & Rasch, 2017; De Las Cuevas et al., 2018). Second is cumulating research evidence indicating that participants’ perceptions of the treatments (i.e. experimental intervention and comparison treatment) under evaluation affect their behaviors in an evaluation study. The behaviors are related to participants’ enrollment and continued participation in the study, which threaten external validity, as well as their engagement and enactment of the allocated treatment. These behaviors affect their experience of improvement in the outcomes, which threaten internal validity (Kendra et al., 2015). The significant contribution of acceptance to intervention’s uptake, engagement, enactment, and outcomes in research and practice resulted in its consideration as an important client‐centered parameter denoting the success of health interventions (Gebhardt et al., 2013; Rejas et al., 2013). Accordingly, acceptance demands special attention in intervention evaluation research. It should be explored when: In this chapter, explanations of how perceived acceptance is formulated within an intervention evaluation study are presented. The importance of examining clients’ perceived acceptance of interventions to enhance validity of inferences is highlighted. Measures and methods for examining acceptance are discussed. Acceptance is an umbrella term entailing favorable perceptions of the experimental intervention and the comparison treatment included in an evaluation study. The perceptions have been reflected in treatment acceptability, preferences, credibility, expectancy, and satisfaction. These perceptions are formulated early in an evaluation study and may change over the course of the study. Clients present with the health problem that is addressed by the treatments under evaluation. Clients differ in their personal profile, health status, beliefs about the health problem, and awareness and values of its treatment, all of which shape their acceptance of the intervention and the comparison treatment. Clients of diverse socioeconomic backgrounds differ in their acceptability of treatment for the presenting health problem, as illustrated in the results of several studies. For example, older persons find medications as acceptable for managing sleep problems (Omvik et al., 2010). Women consider counseling or psychotherapy as acceptable for treating depression (Houle et al., 2013). Persons self‐identifying as non‐white indicate higher acceptance of telephone, compared to internet, delivery of programs for self‐management of chronic conditions (Sarkar et al., 2008). Clients’ general health and experience of the health problem are reported to influence their perceptions of treatment. For instance, clients experiencing severe levels of the health problem are likely to find intensive or invasive treatments as acceptable for the remediation of a range of problems (e.g. Dobscha et al., 2007; Gum et al., 2006; Omvik et al., 2010). Clients of diverse sociocultural backgrounds hold personal and normative beliefs about health in general and the health problem in particular. Beliefs about the health problem are also referred to as illness representation and etiological model. Clients’ understanding of the problem and of its possible causes vary and shape their perspectives on what they consider as appropriate treatments or remedies to manage the problem and improve general health (Cohen et al., 2015). For example, clients’ beliefs about the causes of mental health problems are found to influence their acceptance of pharmacological and non‐pharmacological therapies. Those who believe in the organic (biological, chemical, or genetic) causes of depression (Kemp et al., 2014; Steidtmann et al., 2012; Wright et al., 2012) or insomnia (Bluestein et al., 2011) express acceptance of medications; whereas clients who consider life stress as the primary cause of these mental health problems view non‐pharmacological or psychological therapies, aimed at reducing stress, as acceptable (Givens et al., 2007). Clients are aware of alternative treatments for addressing the health problem they experience. A range of pharmacological, physical, psychological or behavioral, and complementary/alternative treatments are available. Clients acquire knowledge about treatments from many sources. Treatment‐related information is accessible through the internet or World Wide Web; reported in short articles published in newspapers, newsletters or magazines; and presented in documentaries, discussed in health‐related sections of daily news or in other general talk shows aired on radio or television. Clients may also learn about treatments through discussion with family members, friends, or colleagues, and through interactions with health professionals (Mills et al., 2011). Furthermore, clients may have personal or vicarious experience with treatments, that is, they may have actually used a treatment or witnessed others’ use it. They formulate favorable perceptions of treatments reported to be successful and fitting with their beliefs about the health problem. Similar to clients in practice, participants entering an intervention evaluation study present with preconceived beliefs about the health problem and acceptance or value of possible treatments (Kowalski & Mrdjenovich, 2013), which influence their perceptions of the treatments under evaluation. During recruitment, participants are briefly told of the treatments under evaluation. For instance, advertisement for a study evaluating the behavioral therapies for insomnia can specify the general type of treatment, stating: “the treatment does not involve mediation.” When describing the study prior to obtaining consent, and as required by research ethics, participants are provided information on the treatments, without necessarily revealing which is the experimental and which is the comparison treatment. The information covers the treatments’ name (e.g. stimulus control therapy); key or main components (e.g. set of recommendations to do during the day, around bedtime, and during night‐time awakenings); mode and dose of delivery (e.g. given in four, face‐to‐face group sessions, offered once a week); benefits (e.g. found effective in promoting sleep); and risks or discomfort (e.g. experience of daytime fatigue in the first couple of weeks). This information clarifies the treatments to participants and contributes to their perception of the treatments. Participants may compare and contrast their understanding of the treatments under evaluation, with their beliefs about the health problem as well as with their awareness and previous experience with other treatments for addressing the problem. This comparison contributes to the identification of the treatment that is most congruent with their beliefs. Congruent treatments are perceived favorably, whereas incongruent treatments are perceived unfavorably. At this early stage of an evaluation study, participants may express acceptability and preferences for the treatments. Acceptability and preferences reflect two separate but inter‐related perceptions of an intervention’s acceptance. Consenting participants are exposed to the treatment to which they are assigned. The treatments, and in particular health interventions, are provided in individual or group sessions facilitated by an interventionist, or in modules completed by participants. The first session or module is often designed to cover detailed information about the treatment as summarized and illustrated in Table 11.1. The detailed information may reinforce participants’ acceptance or alter their perceptions of the treatments. In particular, information on treatments’ rationale and effectiveness contributes to the formation of their perceived credibility and expectancy, respectively. Participants who view the treatment rationale as credible and expect the treatment to be potentially effective in addressing the health problem and in improving health maintain favorable perceptions (or acceptance) of the allocated treatment; otherwise, participants develop unfavorable perceptions of treatment. Both credibility and expectancy influence participants’ engagement and enactment of the treatment. TABLE 11.1 Treatment information covered in first intervention session or module. Participants’ exposure, engagement, enactment, and experiences with the treatment may or may not be rewarding. Those who appropriately engage and enact the treatment have great potentials of exhibiting the hypothesized improvement in outcomes; others may not benefit from the treatment. These experiences translate into expressed (dis)satisfaction with treatment, which reflect continued acceptance or changes in perceptions of the treatment. Satisfaction with treatment affects participants’ continued use of the treatment and achievement of ultimate outcomes. Mounting evidence supports the contribution of perceived treatment acceptance to the validity of inferences in evaluation studies. Acceptance is represented by perceived treatment’s acceptability, preference, credibility, expectancy, and satisfaction. The evidence demonstrates direct and indirect associations between treatment perceptions and immediate, intermediate, and ultimate outcomes. The direct associations are reflected in parameters quantifying the correlation or differences in the outcomes reported for participants with varying levels of treatment acceptance. The indirect relationships are explained by participants’ behaviors: Participants expressing different perceptions of the treatments under evaluation may behave differently over the course of an evaluation study. Participants’ behaviors are related to their enrollment in and withdrawal (or attrition) from the study, as well as engagement and enactment of the allocated treatment. These behaviors influence the achievement of beneficial outcomes (issue of internal validity) and limit the generalizability of findings (issue of external validity). The way in which treatment perceptions influence participants’ behaviors and experience of outcomes is explained next. Supporting evidence is also presented. The direct association between treatment perceptions and outcomes is well supported empirically; however, the exact mechanism explaining it is not clear. The direct association may represent the placebo response. The placebo response may reflect participants’ expectancy of the intervention effectiveness or their perceptions and responses to the interventionist. Participants perceiving the allocated treatment favorably anticipate that it will be helpful in addressing the health problem. This anticipated helpfulness, or expectancy, translates into reported improvement in outcomes following treatment, regardless of the levels of exposure, engagement, enactment, or adherence to treatment (Frisaldi et al., 2017; Gaudiano et al., 2013; Younger et al., 2012). Participants’ perceptions and reactions to the interventionists are related to the interventionists’ competence, as discussed in Chapter 8. Participants respond positively to interventionists who are able to initiate and build good therapeutic relationships and working alliance, to communicate clearly, and to interact with respect; these participants report improvement in outcomes, regardless of their engagement and enactment of treatment. The distribution of participants exhibiting these placebo responses in the experimental intervention and the comparison treatment groups affect the validity of inferences in an evaluation study. When only participants assigned to the experimental intervention group exhibit placebo responses, then the level of improvement in the outcome is augmented, demonstrated in overestimated effects of the intervention. In this case, it would be difficult to tease out the true effects of the intervention from the placebo effects; thus, the placebo responses confound the intervention’s effects. When only participants allocated to the comparison treatment group show placebo responses, then differences between the experimental and the comparison treatments in the outcomes are small and nonsignificant, resulting in underestimated effects of the intervention; this situation leads to type II error. A similar situation of increased likelihood for type II error is observed when participants in both treatment groups exhibit placebo responses (Colagiuri, 2010). There is ample evidence linking acceptance, reflected in different treatment perceptions, to outcomes. The results of several studies evaluating psychological, behavioral, and surgical treatments (e.g. Beard et al., 2011; El‐Alaoui et al., 2015; Haanstra et al., 2015; Herdman et al., 2012; Mooney et al., 2014; Narimatsu et al., 2016; Nordgreen et al., 2012) were consistent with those of a meta‐analysis (Constantino et al., 2018) in demonstrating a direct positive association between credibility and outcomes. This association implies that participants with high credibility ratings reported large improvement in the outcomes. Similar positive direct relationships between expectancy and outcomes (e.g. Beard et al., 2011; Beasly et al., 2017; Boettcher et al., 2013; El‐Alaoui et al., 2015; Haanstra et al., 2015) and between satisfaction and outcomes (e.g. Köhler et al., 2015; Peyrot & Rubin, 2009; Schaal et al., 2017; Schulte et al., 2011) were found. Clients’ perceived acceptability and preferences for treatment influence their enrollment in an evaluation study. Some clients may view both the experimental intervention and the comparison treatment as unacceptable. They decline enrollment and seek treatment for their health problem outside the study (Mills et al., 2011). Two situations ensue when a large number of recruited clients refuse enrollment. The first situation is a reduced sample size, which lowers the statistical power to detect significant intervention effects on the outcomes (Kowalski & Mrdjenovich, 2013). The second situation is the demand for additional resources to expand recruitment efforts in order to acquire the required sample size. Additional resources may not always be accessible, thereby limiting the accrual of the required sample size. Other clients may perceive one or both treatments under evaluation as acceptable and express preferences for the acceptable treatment. They enroll in the study with the hope to receive the treatment they prefer. Clients perceiving treatments as unacceptable and those viewing treatments as acceptable may differ on some personal and health characteristics, as indicated by evidence presented in Section 11.1. Accordingly, clients with unfavorable perceptions who do not enroll may differ in their personal and health profiles from clients with favorable perceptions who participate in the study. These differences result in a sample that is not representative of all subgroups comprising the target client population (Kowalski & Mrdjenovich, 2013); these differences also introduce biased estimates of the intervention effects that do not replicate in other research studies and in practice (Leykin et al., 2007). The biased estimates are due to the actual participants’ characteristics that confound or are correlated with the intervention effects. Clients who enroll in an evaluation study become aware of the method used for assignment to treatment, and then of the treatment to which they are assigned. Participants with varying levels of acceptability and preferences to the study treatments may react differently to the method of assignment and to the allocated treatment, contributing to withdrawal from the study or the treatment (Fernandez et al., 2015; Steidtmann et al., 2012). The method of assignment is based on chance (i.e. randomization) or preference (Chapter 15). Participants who view both the experimental intervention and the comparison treatment as acceptable and have no strong preferences for either, are indifferent to the method of assignment. They realize that, with chance or preference‐based methods, they will be allocated to any treatment they perceive favorably. Their reactions to the method of assignment and to the allocated treatment are positive or neutral, contributing to their continued involvement in the treatment and/or study. Thus, these participants do not withdraw from the treatment or the study. Participants expressing high levels of acceptability and strong preferences for a particular treatment (either experimental or comparison) react in different ways to chance and preference‐based methods of allocation. Many react negatively to randomization. They consider it as unacceptable and unfair because it disregards their right to be actively involved in the process of treatment decision‐making and their desire to receive their preferred treatment. This group of participants is likely to decline further participation in the study because of discomfort with being randomized to the non‐ or the least‐preferred treatment. Other participants realize that randomization is potentially useful: After all, they have 50% chance of being allocated to their preferred treatment. They may continue their participation in the study (Bradley‐Gilbride & Bradley, 2010). In contrast, participants with high acceptability and strong preference for a particular treatment react positively to preference‐based method of assignment. They are enthusiastic about the prospect of receiving their preferred treatment and continue their involvement in the study. Once known, participants are informed of the treatment to which they are assigned. Participants who are allocated to the treatment that matches their preference are content and continue their involvement in the study. Participants allocated to the treatment that does not match their preference (mismatch) are disappointed. They may withdraw from the study to seek their preferred treatment outside the study. If a large number of participants with mismatched treatment drop out, then the study sample size and power to detect significant treatment effects are reduced. Further, the estimated effects are biased, because the estimates are based on outcome data obtained from a subgroup of participants with matched treatment, high enthusiasm and motivation to enact treatment, and possibly with unique personal and health profiles. Participants who continue their involvement in the evaluation study are exposed to the assigned treatment. Those allocated to a no‐treatment control or treatment‐as‐usual and receive no information or interaction with the study’s interventionist may lose enthusiasm for treatment. Loss of enthusiasm is heightened if the allocated treatment does not match their preference. These participants lose interest in the study, and are likely to withdraw at any time during the treatment or the study period. This situation leads to higher attrition rates in the comparison treatment group than in the experimental intervention group. The number of participants who complete the study is unbalanced between the two groups, potentially resulting in unequal within‐group variance, which decreases the chance of detecting significant intervention effects if not addressed properly in the statistical analysis (Sidani, 2015). Participants allocated to the experimental intervention attend the first session and are exposed to detailed information about the intervention’s rationale, components, benefits, and risks. Those who continue to hold favorable perceptions, indicated by high credibility and expectancy, of the allocated treatment maintain their enthusiasm and motivation to complete treatment (Kendra et al., 2015; Mooney et al., 2014). This group of participants show low attrition rates. Participants who develop unfavorable perceptions of the allocated treatment, indicated by low credibility and expectancy, may express discontentment and withdraw from the treatment or the study, resulting in high attrition rates in this treatment group. The distribution of participants having favorable and unfavorable perceptions of the allocated treatment within the experimental intervention and the comparison treatment groups affects the validity of an evaluation study findings. If the number of participants who withdraw is comparable in the experimental intervention and the comparison treatment groups, then the two groups’ size and the power to detect significant between‐group differences in the outcomes at post‐test are reduced. This, in turn, increases the chance of type I error, that is, inferring that the intervention is not effective when it may be. If the number of participants who drop out is not comparable for the experimental intervention and the comparison treatment groups, then differential attrition is likely. Differential attrition refers to the situation where the number and the personal or health profile of participants who withdraw from one group differ from those of participants who drop out of the other group. Differences in profiles could confound the intervention effects. The contribution of treatment preferences (rather than acceptability), credibility, and expectancy to attrition has been investigated. The results of individual studies and systematic reviews were consistent in showing lower attrition rates for participants allocated to a treatment that matches their preferences (Sidani et al., 2015; Swift et al., 2011, 2013; Wasmann et al., 2019; Winter & Barber, 2013). In addition, participants having low credibility (Boettcher et al., 2013; Merincavage et al., 2017; Narimatsu et al., 2016) and low expectancy (Zimmermann et al., 2017) ratings of the allocated treatment were likely to withdraw. After exposure to treatment information in the first session or module, participants who continue to view the allocated treatment favorably (i.e. high credibility and expectancy ratings) maintain their enthusiasm for the treatment. They attend the remaining sessions or complete the remaining modules, while actively engaging in the planned activities and enacting the treatment recommendations (Beatty & Binnion, 2016; Haanstra et al., 2015). In contrast, participants who no longer view the allocated treatment favorably (i.e. low credibility and expectancy ratings) may lose their motivation. Some may not attend or complete the remaining sessions or modules, but provide outcome data at post‐test. Others may be selective in the sessions or modules they complete, in their level of engagement in the planned activities, and in the treatment recommendations they enact. Therefore, participants assigned to each treatment may vary in their level of adherence to treatment recommendations and, consequently, in their experience of improvement in outcomes. High within‐group variance in the outcomes assessed at post‐test decreases the power to detect significant between‐group differences, potentially leading to type II error. Furthermore, some participants with unfavorable perceptions of the allocated treatment may seek and implement additional therapies to manage their health problem. Receipt of additional therapy, concurrently with the allocated treatment (i.e. co‐treatment) weakens the confidence in attributing improvements in outcomes, specifically and solely, to the intervention under evaluation. The improvements may be the independent effects of the concurrent therapy or the interaction effects of the concurrent therapy and the allocated treatment. Several studies examined the association between treatment perceptions (credibility, expectancy and satisfaction) and adherence to treatment recommendations. Despite variability in the type of intervention evaluated (e.g. physiotherapy, cognitive‐behavioral therapy), the results were consistent in demonstrating that participants rating the allocated treatment as credible, had high expectancy for its effectiveness. The results also converged in showing that participants satisfied with the allocated treatment reported high levels of engagement (Hundt et al., 2013; Kwan et al., 2010) and enactment or adherence to its recommendations (Alessi & Rasch, 2017; Beatty & Binnion, 2016; Boettcher et al., 2013; De Las Cuevas et al., 2018; Dong et al., 2018; Eaton et al., 2019; El‐Alaoui et al., 2015; Narimatsu et al., 2016; Wong et al., 2015). The association between satisfaction and enactment was also found in a systematic review (Barbosa et al., 2012). Evidence (presented previously) clearly indicates that perceptions of treatment influence participants’ enrollment, withdrawal, and engagement and enactment of treatment, which in turn contribute to their experience of improvement in outcomes. As such, treatment perceptions are potential threats to validity. Therefore, it is critical to assess participants’ perceived acceptability, preferences, credibility, expectancy, and satisfaction, and to account for their influence in outcome analysis (Beasly et al., 2017; Sidani & Fox, 2020) in intervention evaluation research. Acceptability of health interventions reflects clients’ attitudes toward treatments. The formulation of the attitude is guided by an understanding of the treatments and is based on judgments of the treatments’ attributes. Participants need to have a clear, accurate, and adequate understanding of the treatments under consideration before they appraise their acceptability. This understanding encompasses knowledge of the treatments’ goals, components, mode of delivery, dose, benefits in addressing the health problem, and associated risks or discomfort (Sidani et al., 2006, 2009). This understanding is foundational for making informed judgments of the treatments’ attributes. The attributes commonly reported of relevance to participants appraising health interventions are: Acceptability, therefore, is operationalized as the desirability of an intervention to potential users or clients or participants. It is inferred from their judgment of the extent to which the intervention’s techniques or procedures are appropriate, effective, convenient to use, and associated with no or minimal risks (Kazdin, 2006; Sekhon et al., 2017, 2018). This perspective has implications for the assessment of acceptability. Measures of acceptability should be designed to involve participants in the judgment of the treatments’ attributes. Assessment of acceptability can be done at different stages of the intervention design and evaluation, using quantitative and qualitative approaches. A range of self‐report instruments and objective indicators have been used to measure acceptability of health interventions. Commonly used ones are briefly reviewed. Several self‐report instruments have been developed, adapted, and validated to measure acceptability of a range of interventions. Carter (2007) reviewed instruments frequently used to assess acceptability of educational and psychological interventions. The Treatment Evaluation Inventory (Kazdin, 1980), the Intervention Rating Profile (Witt & Elliott, 1985), and the Treatment Acceptability Rating form (Reimers et al. in 1992) were the most commonly used or adapted to measure acceptability of specific therapies. Other instruments have been recently generated to assess the acceptability of health and behavioral interventions. Examples include the Treatment Acceptability/Adherence Scale (Milosevic et al., 2015), the Acceptability of Intervention Measure (Weiner et al., 2017), and the Treatment Perception and Preference Scale (Sidani et al., 2018). In addition, single items have been used to measure clients’ perception of an intervention’s overall acceptability (e.g. Schmidt et al., 2015) or specific attributes such as helpfulness or convenience (e.g. Lengel & Mullins‐Sweat, 2017; Miner et al., 2016). Different objective indicators have been used to assess acceptability in intervention evaluation research. The indicators represent participants’ behaviors over the course of the study. The behaviors are mentioned in Section 11.2 as associated with perceptions of treatments. The indicators of acceptability commonly reported include: enrollment rates, reasons for declining enrollment, attrition, reasons for withdrawal, attendance at treatment sessions or self‐completion of modules, adherence to treatment recommendations, and reasons for nonadherence (Beard et al., 2011; Saracuta et al., 2018). These objective indicators are inconsistent with the conceptualization of acceptability as an attitude toward or perceived desirability of treatment (Section 11.3.1). They represent participants’ behaviors in a study that are influenced by perceived acceptability and that may be associated with other factors; the factors are related to the personal and health characteristics of participants (e.g. lack of transportation, functional limitations) and the characteristics of the research study (e.g. burdensome data collection or invasive procedures) (Sidani, 2015). Accordingly, the behaviors are not directly and solely reflective of perceived acceptability of the treatment; they are inaccurate indicators of acceptability. The selection of measures should be informed by a clear conceptualization and operationalization of acceptability in order to enhance construct validity (Chapter 10). As presented in Section 11.3.1, acceptability is conceptualized as an attitude toward treatments. Attitudes are best assessed with self‐report instruments. Acceptability is operationalized as desirability, formed on the basis of judgment of the treatment attributes. Accordingly, self‐report instruments should be designed to involve participants in the appraisal of treatments’ attributes. The self‐report instruments mentioned previously vary in their content; some inquire about overall acceptability and others capture different combinations of treatment attributes to appraise. The Treatment Evaluation Inventory (Kazdin, 1980) and the Treatment Perception and Preference Scale (Sidani et al., 2018) involve the appraisal of the four attributes (appropriateness, effectiveness, risks, and convenience) commonly reported of relevance to clients. To adequately assess acceptability, the self‐report instruments should provide a description of the intervention being appraised. The description includes what the intervention is set to achieve (i.e. its goals), what it consists of (i.e. components), how it is delivered (i.e. mode and dose), and what are its benefits and risks (Witteman et al., 2015). The information is essential for participants to gain an understanding of the intervention, prior to judging it relative to the four attributes. The description is generated from relevant theoretical literature defining the intervention’s active ingredients, clinical or health sources including the manual operationalizing the active ingredients into components, and empirical evidence supporting the intervention’s benefits and identifying possible risks or discomfort. The description is structured and presented in sections covering the intervention’s name; purpose; components or activities; schedule (i.e. mode of delivery, number, length and frequency of the sessions or modules); benefits; and risks. This structure makes it easy for clients to recognize the different aspects of the intervention. The information is given in factual statements that report on the aspects of the intervention without any implication of their importance or value. In other words, the information should not reflect professional opinion or any bias in presentation. This is necessary to ensure that participants’ appraisal is based on facts, on their understanding of the intervention, and on their own values. In addition, nontechnical, clear and simple to understand (at 4th to 6th reading level) terms are used to describe the intervention (refer to Sidani et al., 2009
CHAPTER 11
Examination of Interventions’ Acceptance
11.1 FORMULATION OF INTERVENTION ACCEPTANCE
Personal and health profiles
Beliefs about health problem
Awareness of treatment
Formulation of acceptance in an evaluation study
Treatment information
Illustration—stimulus control therapy
Goal:
What is the treatment set to achieve?
To help manage insomnia
To improve the quality of sleep and daytime functioning
Rationale:
Why and how the treatment works?
Reassociating the bed with sleep
Components (content and activities):
What does the treatment consist of?
Component 1—sleep hygiene
Discussion of recommended activities to do or avoid during the day (e.g. engage in physical activity) or evening (e.g. avoid napping)
Component 2—stimulus control
Discussion of changes to make in the bedroom (e.g. avoid watching television in bed or reading in bed)
Discussion of strategies to do if unable to sleep (e.g. get out of bed and engage in relaxing activities)
Side effects:
What are risks or discomfort associated with the treatment?
Experience of daytime fatigue in the first two weeks of therapy
Effectiveness:
What are the benefits of the treatment?
This therapy was found, in research, to improve sleep for persons who follow all recommendations
11.2 CONTRIBUTION OF PERCEIVED ACCEPTANCE TO VALIDITY
11.2.1 Treatment Perceptions and Outcomes
11.2.2 Treatment Perceptions and Enrollment
11.2.3 Treatment Perceptions and Attrition
11.2.4 Treatment Perceptions and Implementation
11.3 EXAMINATION OF ACCEPTABILITY
11.3.1 Conceptualization of Acceptability
11.3.2 Measures of Acceptability
Self‐Report Instruments
Objective Indicators
Selection of Measures
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