The Effectiveness of Two Implementation Strategies for Improving Teachers' Delivery of an Evidenced-based HIV Prevention Program

Teachers' Perceptions of the Impact of the COVID-19 Pandemic and Their Implementation of an Evidence-based HIV Prevention Program in the Bahamas

Information on how school-based programs is implemented and sustained during crises is limited. In this study, we assessed the impact of the COVID-19 pandemic on the implementation of a HIV prevention intervention in The Bahamas. Data were collected from 139 Grade 6 teachers in 2021-2022. Teachers attended virtual training and received implementation monitoring from coordinators. On average, teachers taught 26.4 (SD = 9.2) of the 35 core activities, and 7.4 (SD = 2.4) out of 9 sessions. More than half (58.3%) of teachers completed 28 or more core activities; 69.1% covered eight or all nine sessions, which is equivalent to 80% of the HIV intervention curriculum. Almost half of the teachers (43%) reported that the pandemic negatively impacted their ability to teach the program; 72% of teachers maintained that the program remained "very important" during times of crisis. Greater self-efficacy and supports increased implementation fidelity.

Maintaining Program Fidelity in a Changing World: National Implementation of a School-Based HIV Prevention Program

Large-scale, evidence-based interventions face challenges to program fidelity of implementation. We developed implementation strategies to support teachers implementing an evidence-based HIV prevention program in schools, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT) in The Bahamas. We examined the effects of these implementation strategies on teachers' implementation in the subsequent year after the initial implementation during the COVID-19 pandemic. Data were collected from 79 Grade 6 teachers in 24 government elementary schools. Teachers completed training workshops and a pre-implementation questionnaire to record their characteristics and perceptions that might affect their program fidelity. School coordinators and peer mentors provided teachers with monitoring, feedback, and mentoring. In Year 1, teachers on average taught 79.3% of the sessions and 80.8% of core activities; teachers in Year 2 covered 84.2% of sessions and 72.9% of the core activities. Teachers with "good" or "excellent" school coordinators in the second year taught significantly more sessions on average (7.8 vs. 7.0, t = 2.04, P < 0.05) and more core activities (26.3 vs. 23.0, t = 2.41, P < 0.05) than teachers with "satisfactory" coordinators. Teachers who had a "good" or "satisfactory" mentor taught more sessions than teachers who did not have a mentor (7.9 vs. 7.3; t = 2.22; P = 0.03). Two-level mixed-effects model analysis indicated that teachers' program fidelity in Year 1, confidence in the execution of core activities, and school coordinators' performance were significantly associated with Year 2 implementation dose. Implementation of FOYC + CImPACT was significantly associated with improved student outcomes. Teachers maintained high fidelity to a comprehensive HIV prevention program over 2 years during the COVID-19 pandemic. Future program implementers should consider additional implementation support to improve the implementation of school-based programs.

Effects of Teacher Training and Continued Support on the Delivery of an Evidence-Based HIV Prevention Program: Findings From a National Implementation Study in the Bahamas

BACKGROUND

Few studies have investigated the effects of teacher training and continued support on teachers' delivery of evidence-based HIV prevention programs. We examined these factors in a national implementation study of an evidence-based HIV risk reduction intervention for adolescents in the sixth grade in the Bahamas.

METHODS

Data were collected from 126 grade 6 teachers and 3,118 students in 58 government elementary schools in the Bahamas in 2019-2021. This is a Hybrid Type III implementation study guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) model. Teachers attended 2-day training workshops. Trained school coordinators and peer mentors provided biweekly monitoring and mentorship. We used mixed-effects models to assess the effects of teacher training and continued support on implementation fidelity.

RESULTS

Teachers who received training in-person or both in-person and online taught the most core activities (27.0 and 27.2 of 35), versus only online training (21.9) and no training (14.9) (F = 15.27, p < .001). Teachers with an "excellent" or "very good" school coordinator taught more core activities than those with a "satisfactory" coordinator or no coordinator (29.2 vs. 27.8 vs. 19.3 vs. 14.8, F = 29.20, p < .001). Teachers with a "very good" mentor taught more core activities and sessions than those with a "satisfactory" mentor or no mentor (30.4 vs. 25.0 vs. 23.1; F = 7.20; p < .01). Teacher training, implementation monitoring, peer mentoring, teachers' self-efficacy, and school-level support were associated with implementation fidelity, which in turn was associated with improved student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection).

CONCLUSION

Teachers receiving in-person training and those having higher-rated school coordinator and mentor support taught a larger number of HIV prevention core activities. Effective teacher training, implementation monitoring, and peer mentoring are critical for improving implementation fidelity and student outcomes.

Protocol for a multi-country implementation research study to assess the feasibility, acceptability, and effectiveness of context-specific actions to train and support facilitators to deliver sexuality education to young people in out-of-school settings

Comprehensive sexuality education (CSE) is a well-established component of the package of interventions required to improve adolescent sexual and reproductive health and rights. As the international community has increased its emphasis on equity and leaving no-one behind with the Agenda for Sustainable Development, attention has been drawn to the need for complementary CSE programmes to reach young people who are not in school, or whose needs are not met by in-school CSE programmes. CSE in out-of-school contexts presents unique considerations, especially those related to facilitation. In this manuscript, we present the protocol for a multi-country implementation research study in Colombia, Ethiopia, Ghana, and Malawi to assess the feasibility, acceptability, and effectiveness of context-specific actions to prepare and support facilitators to deliver CSE in out-of-school settings to defined groups of young people with varying needs and circumstances. This study will be led by the World Health Organization and the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, in partnership with local research institutions. It will be nested within a multi-country programme led by UNFPA, in partnership with local implementing partners and with financial support from the Government of Norway. This study will shed new insight into what it takes to effectively deliver CSE in out-of-school contexts, to enhance progress towards the achievement of SDG 3 "Ensure healthy lives and promote wellbeing for all at all ages" and SDG 5 "Achieve gender equality and empower all women and girls".

Implementing a school-based HIV prevention program during public health emergencies: lessons learned in The Bahamas

Background

Natural disasters and public health crises can disrupt communities’ capacities to implement important public health programs. A nationwide implementation of an evidence-based HIV prevention program, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT), in The Bahamas was disrupted by Hurricane Dorian and the COVID-19 pandemic, especially in its more remote, Family Islands. We explored the teacher- and school-level factors that affected implementation of the program in these islands during those disruptions.

Methods

Data were collected from 47 Grade 6 teachers and 984 students in 34 government elementary schools during the 2020–2021 school year. Teachers completed a pre-implementation questionnaire to record their characteristics and perceptions that might affect their implementation fidelity and an annual program training workshop. School coordinators and high-performing teachers acting as mentors received additional training to provide teachers with monitoring, feedback, and additional support. Teachers submitted data on their completion of the 9 sessions and 35 core activities of FOYC + CImPACT. The fidelity outcomes were the number of sessions and core activities taught by teachers.

Results

On average, teachers taught 60% of sessions and 53% of core activities. Teachers with “very good” school coordinators (34% of teachers) taught more activities than those with “satisfactory” (43%) or no (34%) school coordinator (27.5 vs. 16.8 vs. 14.8, F = 12.86, P < 0.001). Teachers who had attended online training or both online and in-person training taught more sessions (6.1 vs. 6.2 vs. 3.6, F = 4.76, P < 0.01) and more core activities (21.1 vs. 20.8 vs. 12.6, F = 3.35, P < 0.05) than those who received no training. Teachers’ implementation was associated with improved student outcomes (preventive reproductive health skills, self-efficacy, and intention).

Conclusions

The Hurricane Dorian and the COVID-19 pandemic greatly disrupted education in The Bahamas Family Islands and affected implementation of FOYC + CImPACT. However, we identified several strategies that supported teachers’ implementation following these events. Teacher training and implementation monitoring increased implementation fidelity despite external challenges, and students achieved the desired learning outcomes. These strategies can better support teachers’ implementation of school-based interventions during future crises.

Comparing standard versus enhanced implementation of an evidence-based HIV prevention program among Bahamian sixth grade students: findings from nationwide implementation trials

Background

Effective implementation strategies are needed to address the challenges encountered by teachers in implementation of evidence-based HV prevention programs in schools. The current study: 1) compares implementation fidelity of Focus on Youth in the Caribbean (FOYC) plus Caribbean Informed Parents and Children Together (CImPACT) intervention using enhanced implementation strategies (including biweekly monitoring/feedback and site-based mentoring) to those using more traditional approach (teacher training only); and 2) evaluates the impact of school coordinators’ and mentors’ performance on teachers’ implementation fidelity and student outcomes.

Methods

Data from an enhanced implementation trial in 2019–2020, involving 24 government primary schools, 79 teachers, and 2252 students, were compared to data from a standard implementation trial in 2011–2012, involving 35 government primary schools, 110 teachers and 2811 students using mixed-effects modeling and structural equation modeling.

Findings

Teachers in the 2019–2020 trial taught more core activities (28.3 vs. 16.3, t = 10.80, P < 0.001) and sessions (7.2 vs. 4.4, t = 9.14, P < 0.001) than those participating in the 2011–2012 trial. Teachers taught > 80% of the intervention curriculum in 2019–2020 compared to 50% curriculum delivery in 2011–2012. Teachers who had a “very good” or “excellent” school coordinator in their schools taught more core activities than those who had a “satisfactory” school coordinator (30.4 vs. 29.6 vs. 22.3, F = 18.54, P < 0.001). Teachers who worked in a school which had a “very good” mentor, taught more core activities than those teachers who did not have a mentor or had only a “satisfactory” mentor (30.4 vs. 27.6; t = 2.96; p = 0.004). Teachers’ confidence in implementing core activities, comfort level with the curriculum, attitudes towards sex education in schools, and perceived principal support were significantly related to increased self-efficacy, which in turn was related to teachers’ implementation fidelity. The degree of implementation was significantly associated with improved student outcomes.

Implications/conclusion

An evidence-based HIV prevention intervention can achieve a high degree of implementation when delivered with enhanced implementation strategies and implementation monitoring. Future program implementers should consider the purposeful selection and training of school coordinators and mentors to support low-implementing teachers as a potentially important strategy when attempting to achieve high-quality implementation of school-based interventions.