Influence of Classroom-Level Factors on Implementation Fidelity During Scale-up of Evidence-Based Interventions

A Multicomponent Preventive Intervention in the Early Elementary Years: A Look at Academic and Social Adjustment Outcomes

Cogent indicated prevention with young children at risk for early onset conduct problems needs to address multiple domains of influence in school and home settings. A multicontextual preventive intervention (MPI) spanning grades one and two was conducted in schools serving economically disadvantaged communities and evaluated separately for boys and girls. The cluster randomized design evaluated children nested within schools receiving either the MPI (6 schools), which consisted of after-school reading-mentoring, home-based family, peer coping-skills, and classroom components, or a control condition (6 schools) involving a school-wide conflict management program without targeted intervention. Drawn at the end of kindergarten based on elevated behavioral difficulties and first-grade attendance at one of the 12 schools, the two subsamples consisted of 193 boys and 171 girls (63% in households with annual income < $15,000; 95% Black children). Extensive fidelity data indicated that the MPI components were well implemented. The two post-intervention third-grade outcomes in this report are academic performance and social/behavioral adjustment. The analyses involved a linear mixed effects model controlling for school. The key finding for the male subsample was that the MPI produced greater overall and language-arts/reading achievement, measured by report cards for the entire third-grade school year, compared with the control group. MPI-control differences did not emerge for externalizing problems and social competence assessed via teacher and parent report. In the face of elevated risk and poverty, the study underscored the importance of contributions from community-based reading-mentors, positive and inclusive classrooms, and nurturing family contexts in achieving academic gains.

Predictors of the sustainability for an evidence-based eating disorder prevention program delivered by college peer educators

BACKGROUND

Despite ongoing efforts to introduce evidence-based interventions (EBIs) into mental health care settings, little research has focused on the sustainability of EBIs in these settings. College campuses are a natural place to intervene with young adults who are at high risk for mental health disorders, including eating disorders. The current study tested the effect of three levels of implementation support on the sustainability of an evidence-based group eating disorder prevention program, the Body Project, delivered by peer educators. We also tested whether intervention, contextual, or implementation process factors predicted sustainability.

METHODS

We recruited 63 colleges with peer educator programs and randomly assigned them to (a) receive a 2-day Train-the-Trainer (TTT) training in which peer educators were trained to implement the Body Project and supervisors were taught how to train future peer educators (TTT), (b) TTT training plus a technical assistance (TA) workshop (TTT + TA), or (c) TTT plus the TA workshop and quality assurance (QA) consultations over 1-year (TTT + TA + QA). We tested whether implementation support strategies, perceived characteristics of the intervention and attitudes towards evidence-based interventions at baseline and the proportion of completed implementation activities during the implementation year predicted three school-level dichotomous sustainability outcomes (offering Body Project groups, training peer educators, training supervisors) over the subsequent two-year sustainability period using logistic regression models.

RESULTS

Implementation support strategies did not significantly predict any sustainability outcomes, although a trend suggested that colleges randomized to the TTT + TA + QA strategy were more likely to train new supervisors (OR = 5.46, 95% CI [0.89-33.38]). Colleges that completed a greater proportion of implementation activities were more likely to offer Body Project groups (OR = 1.53, 95% CI [1.19-1.98]) and train new peer educators during the sustainability phase (OR = 1.39, 95% CI [1.10-1.74]). Perceived positive characteristics of the Body Project predicted training new peer educators (OR = 18.42, 95% CI [1.48-299.66]), which may be critical for sustainability in routine settings with high provider turnover.

CONCLUSIONS

Helping schools complete more implementation activities and increasing the perceived positive characteristics of a prevention program may result in greater sustainment of prevention program implementation.

TRIAL REGISTRATION

This study was preregistered on 12/07/17 with ClinicalTrials.gov, ID NCT03409809, https://clinicaltrials.gov/ct2/show/NCT03409809 .

Validity Evidence for an Observational Fidelity Measure to Inform Scale-Up of Evidence-Based Interventions

As evidence-based interventions are scaled, fidelity of implementation, and thus effectiveness, often wanes. Validated fidelity measures can improve researchers' ability to attribute outcomes to the intervention and help practitioners feel more confident in implementing the intervention as intended. We aim to provide a model for the validation of fidelity observation protocols to guide future research studying evidence-based interventions scaled-up under real-world conditions. We describe a process to build evidence of validity for items within the Session Review Form, an observational tool measuring fidelity to interactive drug prevention programs such as the Botvin LifeSkills Training program. Following Kane's (2006) assumptions framework requiring that validity evidence be built across four areas (scoring, generalizability, extrapolation, and decision), confirmatory factor analysis supported the hypothesized two-factor structure measuring quality of delivery (seven items assessing how well the material is implemented) and participant responsiveness (three items evaluating how well the intervention is received), and measurement invariance tests suggested the structure held across grade level and schools serving different student populations. These findings provide some evidence supporting the extrapolation assumption, though additional research is warranted since a more complete overall depiction of the validity argument is needed to evaluate fidelity measures.

Examining the Role of Student Responsiveness in Treatment Effects of a Tier 2 Program Targeting Reductions in Problem Behavior

Student responsiveness's role in promoting intervention outcomes for students who exhibit problem behavior is understudied. Due to the relational nature of many interventions delivered by teachers that target social, emotional, or behavioral outcomes of students in classrooms, it is essential to assess how responsive students are to teachers' attempts to engage them in the intervention, particularly for students with problem behaviors that may impede teachers' attempts to engage these students in intervention effectively. In the current study, we combine samples from four randomized controlled trials to examine the relationship between student outcomes and teacher attempts to deliver BEST in CLASS, a Tier 2 intervention, via student responsiveness. Delivery of BEST in CLASS and student responsiveness were assessed through direct observations and teachers' reported measures. Results suggest that teacher adherence and competence in delivering BEST in CLASS practices was associated with reductions in problem behavior from pretest to post-test via student responsiveness. Limitations of the current study and implications for future research are discussed.

Sustainment of an Evidence-Based, Behavioral Health Curriculum in Schools

The development of evidence-based interventions (EBIs) for the prevention of behavioral health problems is well supported. However, limited data exist on the sustainability of EBIs once initial support has ceased. The current study assessed, at 2 years after initial start-up support: (1) What percent of schools sustained EBI implementation? (2) To what degree did sustaining schools implement the EBI with fidelity? (3) What were the primary reasons for not sustaining the EBI? (4) What theoretical and contextual factors during initial start-up support predicted sustainment of the EBI? The study used process evaluation data from the dissemination of the Botvin LifeSkills Training (LST) middle school program in 158 school districts (including 419 schools). Fifty-one percent of districts sustained the EBI and most of these sustaining districts reported following key fidelity guidelines. Primary reasons for discontinuing centered around low teacher or administrative support and turnover. Significant predictors of sustaining LST were higher ratings of LST's complexity, benefit, and compatibility by teachers; more positive perceptions of organizational support from administrators; and smaller proportions of Black students. Results show that EBI sustainment and fidelity of implementation post-initial startup support are feasible, though likely not for all schools. Findings also suggest that cultivating support for the EBI among staff during start-up support may be helpful for sustainment and that social determinants of a school have a complex relationship with EBI sustainment. Future research should explore true causes of differences due to race/ethnicity as well as COVID-19 effects.