A framework for testing and promoting expanded dissemination of promising preventive interventions that are being implemented in community settings

Rationale, Design, and Methods for Nen Unkumbi/Edahiyedo ("We Are Here Now"): A Multi-Level Randomized Controlled Trial to Improve Sexual and Reproductive Health Outcomes in a Northern Plains American Indian Reservation Community

American Indian (AI) youth in the United States experience disproportionate sexual and reproductive health (SRH) disparities relative to their non-Indigenous, white counterparts, including increased rates of sexually transmitted infections (STIs), earlier sexual debut, increased rates of teen birth, and reduced access to SRH services. Past research shows that to improve SRH outcomes for AI youth in reservation communities, interventions must address complex factors and multiple levels of community that influence sexual risk behaviors. Here, we describe development of a multi-level, multi-component randomized controlled trial (RCT) to intervene upon SRH outcomes in a Northern Plains American Indian reservation community. Our intervention is rooted in a community based participatory research framework and is evaluated with a stepped wedge design that integrates 5 reservation high schools into a 5-year, cluster-randomized RCT. Ecological Systems Theory was used to design the intervention that includes (1) an individual level component of culturally specific SRH curriculum in school, (2) a parental component of education to improve parent-child communication about SRH and healthy relationships, (3) a community component of cultural mentorship, and (4) a systems-level component to improve delivery of SRH services from reservation healthcare agencies. In this article we present the rationale and details of our research design, instrumentation, data collection protocol, analytical methods, and community participation in the intervention. Our intervention builds upon existing community strengths and integrates traditional Indigenous knowledge and values with current public health knowledge to reduce SRH disparities.

Measuring Youth Residential Care Provider Attitudes

Abstract. In this study the 15-item Evidence-Based Practices Attitude Scale (EBPAS), a measure designed to assess attitudes toward the adoption of EBPs, was collected from administrators of residential care facilities for youth in the United States. As the EBPAS was administered to a different sample for which it was originally developed (i.e., community mental health), we conducted a Confirmatory Factor Analysis (CFA) to investigate if its factor structure was maintained. Results confirm the factor structure of the EBPAS as a valid measure of attitude toward evidence-based practice among youth residential care providers. Limitations and areas of future research are discussed.

Working on Womanhood (WOW): A participatory formative evaluation of a community-developed intervention

The well-documented disparities in availability, accessibility, and quality of behavioral health services suggest the need for innovative programs to address the needs of ethnic minority youth. The current study aimed to conduct a participatory, formative evaluation of "Working on Womanhood" (WOW), a community-developed, multifaceted, school-based intervention serving primarily ethnic minority girls living in underserved urban communities. Specifically, the current study aimed to examine the feasibility, acceptability, and initial promise of WOW using community-based participatory research (CBPR) and represented the third phase of a community-academic partnership. Qualitative and quantitative data were collected from 960 WOW participants in 21 urban public schools, as well as WOW counselors, parents, and school staff over the course of one academic year. Results demonstrated evidence of acceptability of WOW and noteworthy improvements for WOW participants in targeted outcomes, including mental health, emotion regulation, and academic engagement. Findings also indicated several challenges to implementation feasibility and acceptability, including screening and enrollment processes and curriculum length. Additionally, we discuss how, consistent with participatory and formative research, findings were used by program implementers to inform program improvements, including modifications to screening processes, timelines, curriculum, and trainings - all in preparation for a rigorous effectiveness evaluation.

Challenges Facing Evidence-Based Prevention: Incorporating an Abductive Theory of Method

Current systems used to determine whether prevention programs are "evidence-based" rely on the logic of deductive reasoning. This reliance has fostered implementation of strategies with explicitly stated evaluation criteria used to gauge program validity and suitability for dissemination. Frequently, investigators resort to the randomized controlled trial (RCT) combined with null hypothesis significance testing (NHST) as a means to rule out competing hypotheses and determine whether an intervention works. The RCT design has achieved success across numerous disciplines but is not without limitations. We outline several issues that question allegiance to the RCT, NHST, and the hypothetico-deductive method of scientific inquiry. We also discuss three challenges to the status of program evaluation including reproducibility, generalizability, and credibility of findings. As an alternative, we posit that extending current program evaluation criteria with principles drawn from an abductive theory of method (ATOM) can strengthen our ability to address these challenges and advance studies of drug prevention. Abductive reasoning involves working from observed phenomena to the generation of alternative explanations for the phenomena and comparing the alternatives to select the best possible explanation. We conclude that an ATOM can help increase the influence and impact of evidence-based prevention for population benefit.

Care Coordination Services: A Description of an Alternative Service Model for At-Risk Families

OBJECTIVE

The objective of this article is to describe a care coordination model that includes promising practices which are supported by both practice-based and research-based evidence. This model was developed to address the gaps of other models, namely an emphasis on skill teaching with parents, the flexibility to adapt to the needs of youth with a wide variety of presenting problems, and model fidelity assessment tools to help scale up the program across multiple locations with fidelity.

METHOD

We discuss preliminary administrative and outcome data from 898 youth served across eight locations.

RESULTS

Data suggest positive outcomes at departure from service, as well as 6 months and 12 months post case closure.

CONCLUSION

Preliminary data indicate that youth with educational and behavioral health challenges can benefit from coordination of services that are both youth guided and family driven. As this program has been scaled up and has an established vehicle of dissemination, it is in a unique position to be tested via more highly controlled and rigorous efficacy trials.

Development and Evaluation of a Train-the-Trainer Workshop for Hong Kong Community Social Service Agency Staff

INTRODUCTION

Capacity building approaches are useful in large-scale community-based health promotion interventions. However, models to guide and evaluate capacity building among social service agency staff in community settings are rare in the literature. This paper describes the development and evaluation of a 1-day (7 h) train-the-trainer (TTT) workshop for the "Enhancing Family Well-Being Project". The workshop aimed at equipping staff from different community agencies with the knowledge and skills to design, implement, and evaluate positive psychology-based interventions for their clients in Sham Shui Po, an over-crowded and low-income district in Hong Kong.

METHODS

The current TTT extended and improved on our previous successful model by adding research and evaluation methods (including the Logic Model, process evaluation, and randomized controlled trial), which are important to plan and evaluate the community interventions. Evaluation of the TTT was guided by the Integrated Model of Training Evaluation and Effectiveness (IMTEE), with quantitative and qualitative methods. Quantitative data were collected from pretraining (T1), post-training (T2), and 6-month (T3) and 12-month (T4) follow-up surveys. Qualitative data were collected from four focus groups of agency staff after the intervention.

RESULTS

Ninety-three staff from 30 community agencies attended the training, and 90 completed the baseline survey. Eighty-eight, 63, and 57 staff performed the evaluations at T2, T3, and T4, respectively. Agency staff were satisfied with the TTT. Immediate enhancement of knowledge, self-efficacy, and positive attitudes toward the training content was found at T2 (Cohen's d ranged from 0.24 to 1.22, all p < 0.05). Enhancement of knowledge of all training contents persisted at T3 and T4 (Cohen's d ranged from 0.34 to 0.63, all p < 0.05). Enhancement of self-efficacy in the use of positive psychology in intervention design persisted at T3 (Cohen's d = 0.22, p = 0.04). The skills learned were utilized to plan and develop subsequent interventions. Twenty-nine interventions were successfully designed and implemented by the agency staff, and delivered to 1,586 participants. The agency staff indicated their intention to utilize the skills they had learned for other interventions (score ≥4 out of 6) and to share these skills with their colleagues. Qualitative feedbacks from 23 agency staff supported the quantitative results.

CONCLUSION

Our brief TTT was effectively delivered to a large number of agency staff and showed effects that persisted up to 12 months. Our training and evaluation models may offer a template for capacity building among social service agency staff for community brief, universal family health promotion interventions in diverse settings.

Short- to Midterm Effectiveness of a Brief Motivational Intervention to Reduce Alcohol Use and Related Problems for Alcohol Intoxicated Children and Adolescents in Pediatric Emergency Departments: A Randomized Controlled Trial

OBJECTIVES

The proportion of children and adolescents receiving emergency care for acute alcohol intoxication (AAI) in Germany has sharply increased over the past years. Despite this, no randomized controlled trials (RCTs) have studied guideline- and evidence-based interventions to prevent future alcohol misuse within this population. The objective of our investigation was to evaluate the effectiveness of a brief motivational intervention (b-MI) to reduce drinking and associated problems within pediatric emergency departments (PED) in Hamburg, Germany.

METHODS

This stratified cluster-RCT compared a widely established but modified targeted b-MI and treatment as usual (TAU) for patients recruited and treated on Fridays, Saturdays, or Sundays from July 2011 to January 2014 for AAI in EDs of six pediatric hospitals in Hamburg, Germany. Patients under the age of 18 years and their caregivers were included in the study. Intervention was delivered by trained hospital-external staff. The intervention group (n = 141) received a single-session b-MI with a telephone booster after 6 weeks and a brief consultation for caregivers. All intervention material was manual-based. The TAU control group (n = 175) received youth-specific written information on alcohol use and contact information for community resources. Primary outcomes were changes in binge drinking frequency, number of alcoholic drinks on a typical occasion, and alcohol-related problems using the brief Rutgers Alcohol Problem Index. Outcomes were measured by research assistants not involved in intervention delivery. Baseline data were collected in person at the PED, and follow-up data were collected via telephone 3 and 6 months after baseline. Secondary outcome was postenrollment health service utilization. Analyses were based on linear mixed models and intent to treat.

RESULTS

A total of 86.1% (87.5%) of patients in the b-MI group and 82.4% (86.9%) in the TAU group provided valid outcome data after 3 (6) months, respectively. The differences between groups for all outcomes were statistically nonsignificant at both follow-ups (p > 0.05). After 3 months the mean change in binge drinking frequency was -1.36 (95% confidence interval [CI] = -1.81 to -0.91), a reduction of 62.1% in the b-MI group, and -1.29 (95% CI = -1.77 to -0.95), a reduction of 49.0% in the TAU group. The mean change in number of alcoholic drinks on a typical occasion was -2.24 (95% CI = -3.18 to -1.29), a reduction of 37.5% in the b-MI group, and -1.34 (95% CI = -2.54 to -0.14), a reduction of 26.4% in the TAU group. The mean change of alcohol-related problems was -6.72 (95% CI = -7.68 to -5.76), a reduction of 60.5% in the b-MI group, and -6.43 (95% CI = -7.37 to -5.49), a reduction of 58.3% in the TAU group. The differences in mean changes between groups were similar after 6 months for all outcomes.

CONCLUSION

This study provides new information on the effectiveness of b-MIs delivered at discharge of young AAI patients in emergency care. Both trial groups reduced alcohol use and related problems but the b-MI was not associated with significant effects. Although the intervention approach appears feasible, further considerations of improving the outcomes for this relevant target group are required.

Randomized trial of parent training to prevent adolescent problem behaviors during the high school transition

This randomized controlled trial tested a widely used general parent training program, Common Sense Parenting (CSP), with low-income 8th graders and their families to support a positive transition to high school. The program was tested in its original 6-session format and in a modified format (CSP-Plus), which added 2 sessions that included adolescents. Over 2 annual cohorts, 321 families were enrolled and randomly assigned to either the CSP, CSP-Plus, or minimal-contact control condition. Pretest, posttest, 1-year follow-up, and 2-year follow-up survey data on parenting as well as youth school bonding, social skills, and problem behaviors were collected from parents and youth (94% retention). Extending prior examinations of posttest outcomes, intent-to-treat regression analyses tested for intervention effects at the 2 follow-up assessments, and growth curve analyses examined experimental condition differences in yearly change across time. Separate exploratory tests of moderation by youth gender, youth conduct problems, and family economic hardship also were conducted. Out of 52 regression models predicting 1- and 2-year follow-up outcomes, only 2 out of 104 possible intervention effects were statistically significant. No statistically significant intervention effects were found in the growth curve analyses. Tests of moderation also showed few statistically significant effects. Because CSP already is in widespread use, findings have direct implications for practice. Specifically, findings suggest that the program may not be efficacious with parents of adolescents in a selective prevention context and may reveal the limits of brief, general parent training for achieving outcomes with parents of adolescents. (PsycINFO Database Record

Evaluation of Boys Town In-Home Family Services with Families Referred by Child Welfare

This study evaluated the Boys Town In-Home Family Services model with families referred by child welfare for issues related to maltreatment. Participants were 135 parents (mean age = 32.15 years, SD = 9.13) who completed intake and discharge assessments. The target child ranged in age from one month to 17 years (M = 4.54, SD = 4.38). We had a high-risk sample (e.g., 57% and 41% of parents reported being victims of physical and sexual abuse, respectively; 24% of parents reported attempting suicide in their lifetimes). The intervention was implemented with a degree of fidelity consistent with model standards. Reduced levels of perceived stressors were found for several domains of functioning with the largest effects observed for family safety, parental capabilities, and environmental factors. Results serve as an important step in building the evidence base of a widely disseminated intervention.

Parent Training to Reduce Problem Behaviors over the Transition to High School: Tests of Indirect Effects through Improved Emotion Regulation Skills

Adolescent problem behaviors are costly for individuals and society. Promoting the self-regulatory functioning of youth may help prevent the development of such behaviors. Parent-training and family intervention programs have been shown to improve child and adolescent self-regulation. This study helps fill gaps in knowledge by testing for indirect effects of the Common Sense Parenting® (CSP) program on reduced substance use, conduct problems, and school suspensions through previously identified short-term improvements in parents' reports of their children's emotion regulation skills. Over two cohorts, 321 low income families of 8th graders were enrolled and randomly assigned to either the standard CSP program, an adapted CSP Plus program, or a minimal-contact control condition. Pretest, posttest, 1-year follow-up, and 2-year follow-up survey assessments were completed by parents and students with 94% retention. Intent-to-treat multivariate path analyses were conducted. Neither intervention had statistically significant total effects on the three targeted adolescent outcomes. CSP, but not CSP Plus, had statistically significant indirect effects on reduced substance use and school suspensions at the 1-year follow-up as well as conduct problems and school suspensions at the 2-year follow-up through increased child emotion regulation skills at posttest. Findings provide some support for emotion regulation as one pathway through which the intervention was associated, indirectly, with reduced substance use, conduct problems, and school suspensions among at-risk students over the high school transition.

Fostering Healthy Futures for Teens: Adaptation of an Evidence-Based Program

OBJECTIVE

This article describes the process of adapting and implementing a complex, multicomponent intervention for a new population. Specifically, the article delineates the development and implementation of the Fostering Healthy Futures for Teens (FHF-T) program, which is an adaptation and extension of the Fostering Healthy Futures^® (FHF) preventive intervention. FHF is a 9-month mentoring and skills group program for 9 to 11 year olds recently placed in foster care. Following the designation of FHF as an evidence-based intervention, there was increasing demand for the program. However, the narrow population for which FHF had demonstrated efficacy limited broader implementation of the existing intervention. FHF-T was designed to extend the reach of the program by adapting the FHF intervention for adolescents in the early years of high school who have a history of out-of-home care. Specifically, this adaptation recognizes key developmental differences between preadolescent and adolescent populations.

METHOD

After designing a program model and adapting the program components, the FHF-T mentoring program was implemented with 42 youth over 2 program years.

RESULTS

Of the teens who were offered the program, 75% chose to enroll, and 88% of those graduated 9 months later. Although the program evidenced high rates of uptake and participant satisfaction, some unexpected challenges were encountered that will need to be addressed in future iterations of the program.

CONCLUSIONS

Too often program adaptations are made without careful consideration of important contextual issues, and too infrequently, these adapted programs are studied. Our process of program adaptation with rigorous measurement of program implementation provides a useful model for other evidence-based programs seeking thoughtful adaptation.

Reducing Risks for Problem Behaviors During the High School Transition: Proximal Outcomes in the Common Sense Parenting Trial

This study tests Common Sense Parenting (CSP)®, a widely used parent-training program, in its standard form and in a modified form known as CSP Plus, with low-income 8th graders and their families during the high school transition. The six-session CSP program proximally targets parenting and child emotion regulation skills. CSP Plus adds two sessions that include youth, and the eight-session program further targets skills for avoiding negative peers and activities in high school. Over two cohorts, 321 families were enrolled and randomly assigned to either CSP, CSP Plus, or minimal-contact control conditions. To date, pretest and posttest assessments have been completed, with 93% retention over about a 6-month interval. Here, analyses of preliminary outcomes from pretest to posttest focus on data collected from parents, who represent the primary proximal intervention targets. Intent-to-treat structural equation modeling analyses were conducted. CSP and CSP Plus had statistically significant effects on increased parent-reported child emotion regulation skills. CSP Plus further showed a statistically significant effect on increased parent perceptions of their adolescent being prepared for high school, but only in a model that excluded the CSP condition. Neither program had a significant proximal effect on parenting practices. Emotion regulation, one indicator of self-control, is a robust protective factor against problem behaviors. Intervention effects on this outcome may translate into reduced problems during high school. Moreover, CSP Plus showed some limited signs of added value for preparing families for the high school transition.

Toward scientific equity for the prevention of depression and depressive symptoms in vulnerable youth

Certain subgroups of youth are at high risk for depression and elevated depressive symptoms, and experience limited access to quality mental health care. Examples are socioeconomically disadvantaged, racial/ethnic minority, and sexual minority youth. Research shows that there are efficacious interventions to prevent youth depression and depressive symptoms. These preventive interventions have the potential to play a key role in addressing these mental health disparities by reducing youth risk factors and enhancing protective factors. However, there are comparatively few preventive interventions directed specifically to these vulnerable subgroups, and sample sizes of diverse subgroups in general prevention trials are often too low to assess whether preventive interventions work equally well for vulnerable youth compared to other youth. In this paper, we describe the importance and need for "scientific equity," or equality and fairness in the amount of scientific knowledge produced to understand the potential solutions to such health disparities. We highlight possible strategies for promoting scientific equity, including the following: increasing the number of prevention research participants from vulnerable subgroups, conducting more data synthesis analyses and implementation science research, disseminating preventive interventions that are efficacious for vulnerable youth, and increasing the diversity of the prevention science research workforce. These strategies can increase the availability of research evidence to determine the degree to which preventive interventions can help address mental health disparities. Although this paper utilizes the prevention of youth depression as an illustrative case example, the concepts are applicable to other health outcomes for which there are disparities, such as substance use and obesity.

Washington State recreational marijuana legalization: parent and adolescent perceptions, knowledge, and discussions in a sample of low-income families

BACKGROUND

In November 2012, Washington State and Colorado became the first states in the United States to legalize recreational marijuana use for adults, and Uruguay became the first country to allow the cultivation, distribution, possession, and use of marijuana. One possible consequence of these changes is increased adolescent marijuana use. Parents may mitigate this adverse consequence; however, whether parents and adolescents have accurate knowledge about the laws and are discussing marijuana use in light of the law changes is unknown.

OBJECTIVE

We examine perceptions, knowledge, and parent-child discussions about Washington State's recreational marijuana law in a sample of low-income families.

METHODS

Participants were a subset of families (n = 115) in an ongoing study that originally recruited parents and adolescents from middle schools in Tacoma, Washington. In summer 2013, when students were entering the 11(th) grade, students and their parents were asked questions about the recreational marijuana law.

RESULTS

Participants perceived that their marijuana-related attitudes and behaviors changed little as a result of the law, and displayed uncertainty about what is legal and illegal. Most parents reported discussing the new law with their children but only occasionally, and conversations emphasized household rules, particularly among parent lifetime marijuana users compared to non-users. Conclusions/Importance: Results suggest that there should be a public health campaign focused on families that provides clear information about the recreational marijuana laws.

Implementation assessment of widely used but understudied prevention programs: an illustration from the Common Sense Parenting trial

Common Sense Parenting is a parent-training program that is widely disseminated, has promising preliminary support, and is being tested in a randomized controlled trial that targets lower-income, urban 8th-grade students and their families (recruited in two annual cohorts) to improve the transition to high school. The workshop-based program is being tested in both standard 6-session (CSP) and modified 8-session (CSP Plus) formats; CSP Plus adds adolescent-skills training activities. To offer a comprehensive picture of implementation outcomes in the CSP trial, we describe the tools used to assess program adherence, quality of delivery, program dosage, and participant satisfaction, and report the implementation data collected during the trial. Results indicated that workshop leaders had high adherence to the program content and manual-stated goal times of the CSP/CSP Plus curriculum and delivered the intervention with high quality. The majority of intervention families attended some or all of the sessions. Participant satisfaction ratings for the workshops were high. There were no significant cohort differences for adherence, quality and dosage; however, there were significant cohort improvements for participant satisfaction. Positive fidelity results may be due to the availability of detailed workshop leader guides, in addition to ongoing training and supervision, which included performance-based feedback.