Ethical Challenges in Promoting the Implementation of Preventive Interventions: Report of the SPR Task Force

Validation of a Bayesian learning model to predict the risk for cannabis use disorder

BACKGROUND

Cannabis use disorder (CUD) is a growing public health problem. Early identification of adolescents and young adults at risk of developing CUD in the future may help stem this trend. A logistic regression model fitted using a Bayesian learning approach was developed recently to predict the risk of future CUD based on seven risk factors in adolescence and youth. A nationally representative longitudinal dataset, Add Health was used to train the model (henceforth referred as Add Health model).

METHODS

We validated the Add Health model on two cohorts, namely, Michigan Longitudinal Study (MLS) and Christchurch Health and Development Study (CHDS) using longitudinal data from participants until they were approximately 30 years old (to be consistent with the training data from Add Health). If a participant was diagnosed with CUD at any age during this period, they were considered a case. We calculated the area under the curve (AUC) and the ratio of expected and observed number of cases (E/O). We also explored recalibrating the model to account for differences in population prevalence.

RESULTS

The cohort sizes used for validation were 424 (53 cases) for MLS and 637 (105 cases) for CHDS. AUCs for the two cohorts were 0.66 (MLS) and 0.73 (CHDS) and the corresponding E/O ratios (after recalibration) were 0.995 and 0.999.

CONCLUSION

The external validation of the Add Health model on two different cohorts lends confidence to the model's ability to identify adolescent or young adult cannabis users at high risk of developing CUD in later life.

Study protocol for a cluster-randomized trial of a bundle of implementation support strategies to improve the fidelity of implementation of schoolwide Positive Behavioral Interventions and Supports in rural schools

Background

Improving the implementation of evidence-based interventions is important for population-level impacts. Positive Behavioral Interventions and Supports (PBIS) is effective for improving school climate and students’ behavioral outcomes, but rural schools often lag behind urban and suburban schools in implementing such initiatives.

Methods/Design

This paper describes a Type 3 hybrid implementation-effectiveness trial of Rural School Support Strategies (RS3), a bundle of implementation support strategies selected to improve implementation outcomes in rural schools. In this two-arm parallel group trial, 40 rural public schools are randomized to receive: 1) a series of trainings about PBIS; or 2) an enhanced condition with training plus RS3. The trial was planned for two years, but due to the pandemic has been extended another year. RS3 draws from the Interactive Systems Framework, with a university-based team (support system) that works with a team at each school (school-based delivery system), increasing engagement through strategies such as: providing technical assistance, facilitating school team functioning, and educating implementers. The primary organizational-level outcome is fidelity of implementation, with additional implementation outcomes of feasibility, acceptability, appropriateness, and cost. Staff-level outcomes include perceived climate and self-reported adoption of PBIS core components. Student-level outcomes include disciplinary referrals, academic achievement, and perceived climate. Mediators being evaluated include organizational readiness, school team functioning, and psychological safety.

Discussion

The study tests implementation strategies, with strengths including a theory-based design, mixed methods data collection, and consideration of mediational mechanisms. Results will yield knowledge about how to improve implementation of universal prevention initiatives in rural schools.

Transparent, Open, and Reproducible Prevention Science

The field of prevention science aims to understand societal problems, identify effective interventions, and translate scientific evidence into policy and practice. There is growing interest among prevention scientists in the potential for transparency, openness, and reproducibility to facilitate this mission by providing opportunities to align scientific practice with scientific ideals, accelerate scientific discovery, and broaden access to scientific knowledge. The overarching goal of this manuscript is to serve as a primer introducing and providing an overview of open science for prevention researchers. In this paper, we discuss factors motivating interest in transparency and reproducibility, research practices associated with open science, and stakeholders engaged in and impacted by open science reform efforts. In addition, we discuss how and why different types of prevention research could incorporate open science practices, as well as ways that prevention science tools and methods could be leveraged to advance the wider open science movement. To promote further discussion, we conclude with potential reservations and challenges for the field of prevention science to address as it transitions to greater transparency, openness, and reproducibility. Throughout, we identify activities that aim to strengthen the reliability and efficiency of prevention science, facilitate access to its products and outputs, and promote collaborative and inclusive participation in research activities. By embracing principles of transparency, openness, and reproducibility, prevention science can better achieve its mission to advance evidence-based solutions to promote individual and collective well-being.

The Society for Prevention Research 20 Years Later: a Summary of Training Needs

The Society for Prevention Research (SPR) aims to continually provide relevant professional development training opportunities to advance scientific investigation of ways to improve the health, well-being, and social and educational outcomes of individuals and communities. Our study, led by the Training Needs Assessment Task Force, designed a quantitative questionnaire informed by semistructured, qualitative interviews of 13 key prevention science informants. The questionnaire was deployed to all SPR members, of which 347 completed it. Questions about training topics were asked along 8 categories: (1) theory; (2) preventive interventions; (3) research methods, design, and evaluation; (4) teaching and mentoring; (5) practical and interpersonal skills; (6) communication; (7) project management; and (8) data analysis. Across all categories, respondents reported a high level of interest in receiving training: more than 80% were interested in training in data analytic methods; about 70% indicated interest in theory, preventive interventions, and research methods, design, and evaluation; about 65% were interested in at least 1 communication and project management topic; and 60% showed interest in at least 1 practical and interpersonal skills topic. Training-related interests varied across career level and race/ethnicity, with early-career individuals and people of color typically indicating the most interest. Participants were most likely to endorse self-initiated learning and webinars. SPR preconference training workshops were strongly endorsed for data analysis and preventive intervention topics. Recommendations from our study include a need for SPR to more strongly support self-initiated learning opportunities and continue preconference training programs, with special focuses in statistical methods and preventive interventions and regular assessment of members’ training preferences.

Ethical Dimensions of Public Health Actions and Policies With Special Focus on COVID-19

During pandemics, the ethicists, public health professionals, and human rights advocates raise a red flag about different public health actions that should, at best, be addressed through integrated, global policies. How to rationalize the healthcare resources and prioritize the cases is not a recent challenge but the serious concern about that is how to achieve this while not increasing the vulnerability of the disadvantaged population. Healthcare professionals use different scoring systems as a part of their decision-making so the medical teams and triage committees can allocate resources for predictable health outcomes and prognosis as well as to appropriately triage the patients accordingly. However, the value of the existing scoring systems to manage COVID-19 cases is not well-established yet. Part of this problem includes managing non-COVID patients with chronic medical conditions like non-communicable diseases and addressing their medical needs during the pandemic complex context in a way to avoid worsening their conditions and, on the other hand, avoid hindering the establishment of comprehensive standards for dealing with COVID-19. In this article, we discuss this dilemma as well as how preexisting ethical standards were challenged by COVID-19. We also discuss how monitoring the consistent application of ethical standards during the medical trials of new medications, vaccines, or unproven medical interventions is also a critical issue.

Effects of the Family Check-Up 4 Health on Parenting and Child Behavioral Health: A Randomized Clinical Trial in Primary Care

The Family Check-Up 4 Health (FCU4Health) is an adaptation of the Family Check-Up (FCU) for delivery in primary care settings. While maintaining the original FCU's focus on parenting and child behavioral health, we added content targeting health behaviors. This study evaluated whether the adapted FCU maintained positive effects on parenting (positive behavior support, limit setting, parental warmth) and child behavioral health (self-regulation, conduct problems, emotional problems). Pediatric (6-12 years) primary care patients with a BMI ≥ 85^th%ile (n = 240) were recruited from primary care clinics in Phoenix. Children were 75% Latino, 49% female, and 73% Medicaid recipients. This type 2 effectiveness-implementation hybrid trial compared families randomized to FCU4Health (n = 141) or usual care (n = 99). FCU4Health was delivered over a period of 6 months. This study focuses on a priori secondary outcomes included parenting and child behavioral health targets of the original FCU, assessed at baseline and 3, 6, and 12 months. Significant improvements were found for the FCU4Health condition, compared to usual care, in parenting from baseline to the 3-month assessment [β = .17 (.01; .32)]. Parenting predicted improvements in child self-regulation at 6-months [β = .17 (.03; .30)], which in turn predicted reductions in conduct problems [β = - .38 (- .51; - .23)] and emotional problems [β = - .24 (- .38; - .09)] at 12 months. Ethnicity and language of delivery (English or Spanish) did not moderate these effects. The FCU4Health can improve parenting and child behavioral health outcomes when delivered in primary care.Trial Registration Trial registration number: NCT03013309 ClinicalTrials.gov.

Primary Prevention of Dementia: An Ethical Review

Dementia poses important medical and societal challenges, and of all health risks people face in life, dementia is one of the most feared. Recent research indicates that up to about 40% of all cases of dementia might be preventable. A series of environmental, social, and medical risk-factors have been identified that should be targeted from midlife onwards when people are still cognitively healthy. At first glance, this seems not merely advisable, but even imperative. However, these new developments trigger a series of new ethical questions and concerns which have hardly been addressed to date. Pro-active ethical reflection, however, is crucial to ensure that the interests and well-being of those affected, ultimately all of us, are adequately respected. This is the goal of the current contribution. Against the background of a concrete case in primary dementia prevention, it provides a systematic overview of the current ethical literature and sketches an ethical research agenda. First, possible benefits of increased well-being must be balanced with the burdens of being engaged in particularly long-term interventions for which it is unclear whether they will ever pay out on a personal level. Second, while knowledge about one's options to maintain brain health might empower people, it might also undermine autonomy, put high social pressure on people, medicalize healthy adults, and stigmatize those who still develop dementia. Third, while synergistic effects might occur, the ideals of dementia prevention might also conflict with other health and non-health related values people hold in life.

Toward fostering resilience on a large scale: Connecting communities of caregivers

In interventions for at-risk children, Tom Dishion strongly exhorted programs that are short term, cost-effective, and delivered in families' own communities, just as resilience researchers underscore the need for programs that provide ongoing support for children's primary caregivers, and are implementable on a large scale. Presented here are preliminary results on a short-term intervention for mothers, the Authentic Connections Virtual Groups. A previous randomized trial of the in-person version of this program, conducted with mothers at high risk for stress and burnout, showed significant benefits. There had been zero dropouts across the 3-month program, and participants showed significant improvements on psychological indices as well as cortisol, even 3 months after the program ended. In the present study, virtual groups were conducted with five sets of women, all white-collar professionals with highly stressful, exacting careers, and most also primary caregivers of their children. Again, there were zero dropouts. Mean satisfaction ratings were 9.6 of 10, and the Net Promoter Score (promoters vs. detractors) fell in the "world class" range. To illuminate mechanisms of change, participants' responses to open-ended questions on the groups' value are presented verbatim. Recurrently mentioned were the development of new, authentic connections and invaluable ongoing support. These results, with the low costs and ease of women's attendance, attest to the value of expanding offerings such as these, toward benefiting even more highly stressed mothers themselves as well as the children for whose care they are responsible.

Prevention of eating disorders: 2018 in review

This article reviews the 10 prevention-related publications in Eating Disorders: The Journal of Treatment & Prevention during 2018. Two models frame this analysis. This first is the Mental Health Intervention Spectrum from health promotion → types of prevention → case identification and referral → treatment (recovery). The second parses the phases of prevention into rationale, theory, and methodology → clarification of risk factors, including very high risk, shading into warning signs → implications for specific preventive interventions → design innovation and feasibility (pilot) research → efficacy and effectiveness research → program dissemination. Collectively, the articles illustrate how complex and demanding the field of prevention is, with respect to, for example, phases of program development, the multidimensional ecology of interventions, and methodological requirements for demonstrating that a program deserves to be designated "evidence-based." A subset of the articles also illustrates how far the increasingly broad and dynamic field of prevention has advanced. Examples include models of eating disorder development in high-risk populations such as people with type 1 diabetes; prevention programming for young children; and after-school preventive interventions that combine dissonance-based lessons with empowering participation in community advocacy and activism.

Genomics, Big Data, and Broad Consent: a New Ethics Frontier for Prevention Science

Emerging technologies for analyzing biospecimens have led to advances in understanding the interacting role of genetics and environment on development and individual responsivity to prevention and intervention programs. The scientific study of gene-environment influences has also benefited from the growth of Big Data tools that allow linking genomic data to health, educational, and other information stored in large integrated datasets. These advances have created a new frontier of ethical challenges for scientists as they collect, store, or engage in secondary use of potentially identifiable information and biospecimens. To address challenges arising from technological advances and the expanding contexts in which potentially identifiable information and biospecimens are collected and stored, the Office of Human Research Protections has revised federal regulations for the protection of human subjects. The revised regulations create a new format, content, and transparency requirements for informed consent, including a new mechanism known as broad consent. Broad consent offers participants a range of choices regarding consent for the storage and future use of their personally identifiable data. These regulations have important implications for how prevention scientists and oversight boards acquire participant consent for the collection, storage, and future use of their data by other investigators for scientific purposes significantly different from the original study. This article describes regulatory changes and challenges affecting traditional informed consent for prevention research, followed by a description of the rationale and requirements for obtaining broad consent, and concludes with a discussion of future challenges involving ongoing transparency and protections for participants and their communities.

Multigroup Propensity Score Approach to Evaluating an Effectiveness Trial of the New Beginnings Program

We used a multigroup propensity score approach to evaluate a randomized effectiveness trial of the New Beginnings Program (NBP), an intervention targeting divorced or separated families. Two features of effectiveness trials, high nonattendance rates and inclusion of an active control, make program effects harder to detect. To estimate program effects based on actual intervention participation, we created a synthetic inactive control comprised of nonattenders and assessed the impact of attending the NBP or active control relative to no intervention (inactive control). We estimated propensity scores using generalized boosted models and applied inverse probability of treatment weighting for the comparisons. Relative to the inactive control, NBP strengthened parenting quality as well as reduced child exposure to interparental conflict, parent psychological distress, and child internalizing problems. Some effects were moderated by parent gender, parent ethnicity, or child age. On the other hand, the effects of active versus inactive control were minimal for parenting and in the unexpected direction for child internalizing problems. Findings from the propensity score approach complement and enhance the interpretation of findings from the intention-to-treat approach.