Factors associated with the implementation of the Familias Unidas intervention in a type 3 translational trial

The Role of Intervention Fidelity, Culture, and Individual-Level Factors on Health-Related Outcomes Among Hispanic Adolescents with Unhealthy Weight: Findings from a Longitudinal Intervention Trial

Previous studies have suggested the impact of intervention fidelity on the management and prevention of chronic diseases; however, little is known about the effect of the contributing determinants (at multiple levels of influence) that can impact health-related interventions intending to improve the health status of Hispanic adolescents with overweight or obesity. The current study aimed to assess whether fidelity (i.e., dosage and quality of the program delivery), acculturation (i.e., orientation to the American culture, retention of Hispanic cultural values), and individual-level socio-demographic characteristics (i.e., income, education) predict changes in family processes (e.g., parent control), which in turn may affect adolescent health-related outcomes including body mass index (BMI), physical activity, dietary intake, and adolescents' health-related quality of life. A pathway analysis model was utilized to explore the study variables among 140 Hispanic parent-adolescent dyads randomized to Familias Unidas Health and Wellness (FUHW) intervention. Results indicated that fidelity was significantly associated with changes in parent-adolescent communication, parent monitoring, limit-setting, and control. Parents' education was associated with changes in parent limit-setting, and parent Hispanicism was associated with changes in parent limit-setting and discipline. The examination between family processes and adolescent health outcomes revealed that parents' higher discipline and improved communication with their adolescents were significantly associated with improved adolescents' quality of life, and parent control was positively associated with physical activity and negatively associated with BMI in adolescents. Our findings demonstrated the significant contribution of intervention fidelity and participants' characteristics in parenting strategies leading to adolescents' health outcomes to prevent obesity-related chronic diseases. Future research is needed to investigate the effect of environmental and organizational factors on the delivery of the intervention materials.

The Association Between Facilitator Competent Adherence and Outcomes in Parenting Programs: a Systematic Review and SWiM Analysis

There is increasing interest about the fidelity with which interventions are implemented because it is theorized that better implementation fidelity by facilitators is associated with better participant outcomes. However, in the parenting program literature, there is mixed evidence on the relationship between implementation fidelity and outcomes. This paper provides a synthesis of the evidence on the relationship between facilitator delivery and outcomes in the parenting program literature. Following PRISMA guidelines, this paper synthesizes the results of a systematic review of studies on parenting programs aiming to reduce violence against children and child behavior problems. Specifically, it examines associations between observational measures of facilitator competent adherence and parent and child outcomes. A meta-analysis was not feasible due to study heterogeneity. As a result, Synthesis Without Meta-Analysis guidelines were followed. Searches in electronic databases, reference searching, forward citation tracking, and expert input identified 9653 articles. After screening using pre-specified criteria, 18 articles were included. The review found that most studies (n = 13) reported a statistically significant positive relationship with at least one parent or child outcome. However, eight studies reported inconsistent findings across outcomes, and four studies found no association with outcomes. The results suggest that better facilitator competent adherence is generally associated with positive parent and child outcomes. However, this finding is weakened by the methodological heterogeneity of included studies and due to the wide variety of ways in which studies conceptualized competent adherence-outcome relationships.

eHealth Familias Unidas Mental Health: Protocol for an effectiveness-implementation hybrid Type 1 trial to scale a mental health preventive intervention for Hispanic youth in primary care settings

This article focuses on the rationale, design and methods of an effectiveness-implementation hybrid type I randomized trial of eHealth Familias Unidas Mental Health, a family-based, online delivered intervention for Hispanic families to prevent/reduce depressive and anxious symptoms, suicide ideation/behaviors, and drug use in Hispanic youth. Utilizing a rollout design with 18 pediatric primary care clinics and 468 families, this study addresses intervention effectiveness, implementation research questions, and intervention sustainment, to begin bridging the gap between research and practice in eliminating mental health and drug use disparities among Hispanic youth. Further, we will examine whether intervention effects are partially mediated by improved family communication and reduced externalizing behaviors, including drug use, and moderated by parental depression. Finally, we will explore whether the intervention's impact on mental health and drug use, as well as sustainment of the intervention in clinics, varies by quality of implementation at clinic and clinician levels. Trail registration: ClinicalTrials.gov Identifier: NCT05426057, First posted June 21, 2022.

The "Haves, Have Some, and Have Nots:" a Latent Profile Analysis of Capacity, Quality, and Implementation in Community-Based Afterschool Programs

Implementation of evidence-based practices is a critical factor in whether afterschool programs are successful in having a positive impact upon risk reduction and positive youth development. However, important prevention research reveals that contextual and organizational factors can affect implementation (Bradshaw & Pas in School Psychology Review, 40, 530–548, 2011) (Flaspohler et al., in American Journal of Community Psychology, 50(3-4), 271-281, 2012) (Gottfredson et al., Prevention Science, 3, 43–56, 2002) (McIntosh et al., Journal of Positive Behavior Interventions, 18(4), 209-218, 2016) (Payne in Prevention Science, 10, 151–167, 2009). Using a latent profile approach (LPA), this paper examines multiple organizational and neighborhood contextual factors that might affect the degree to which afterschool programs effectively implement evidence-based practices in the context of a cluster-randomized trial of the Paxis Good Behavior Game (PaxGBG). The Interactive Systems Framework (ISF) explores dimensions of capacity that might matter for prevention efforts. As expected, we found that well-resourced and high-quality programs performed well in terms of implementation (the Haves) and, in neighborhood contexts rich in racial-ethnic diversity. Yet, we found that some programs with less physical and material capacity (the Have Nots), demonstrated greater program quality (i.e., supportive adult and peer relationships, engagement, a sense of belonging) and implementation, relative to programs with better capacity (e.g., space, material resources, staffing, and leadership, the Have Somes). While capacity matters, intentional prevention initiatives that seek to promote evidence-based practices are helpful to sites in supporting organizations that might otherwise fail to provide quality programming for youth. This paper addresses a conundrum in prevention science, namely, how to make programming accessible to those who need it with a focus on organizational processes, program quality, and implementation of evidence-based practices.

County-level factors affecting Latino HIV disparities in the United States

OBJECTIVE

To determine which county-level social, economic, demographic, epidemiologic and access to care factors are associated with Latino/non-Latino White disparities in prevalence of diagnosed HIV infection.

METHODS AND FINDINGS

We used 2016 county-level prevalence rates of diagnosed HIV infection rates for Latinos and non-Latino Whites obtained from the National HIV Surveillance System and factors obtained from multiple publicly available datasets. We used mixed effects Poisson modeling of observed HIV prevalence at the county-level to identify county-level factors that explained homogeneous effects across race/ethnicity and differential effects for Latinos and NL-Whites. Overall, the median Latinos disparity in HIV prevalence is 2.4; 94% of the counties have higher rates for Latinos than non-Latinos, and one-quarter of the counties' disparities exceeded 10. Of the 41 county-level factors examined, 24 showed significant effect modification when examined individually. In multi-variable modeling, 11 county-level factors were found that significantly affected disparities. Factors that increased disparity with higher, compared to lower values included proportion of HIV diagnoses due to injection drug use, percent Latino living in poverty, percent not English proficient, and percent Puerto Rican. Latino disparities increased with decreasing percent severe housing, drug overdose mortality rate, percent rural, female prevalence rate, social association rate, percent change in Latino population, and Latino to NL-White proportion of the population. These factors while significant had minimal effects on diminishing disparity, but did substantially reduce the variance in disparity rates.

CONCLUSIONS

Large differences in HIV prevalence rates persist across almost all counties even after controlling for county-level factors. Counties that are more rural, have fewer Latinos, or have lower NL-White prevalence rates tend to have higher disparities. There is also higher disparity when community risk is low.

Short-Term Effects on Family Communication and Adolescent Conduct Problems: Familias Unidas in Ecuador

Familias Unidas, a Hispanic/Latino-specific, parent-centered intervention, found to be efficacious in improving family functioning and reducing externalizing behaviors among youth in the USA, was recently adapted and tested for use in Ecuador. This study examined the short-term efficacy of Familias Unidas in Ecuador on parent-adolescent communication, parental monitoring of peers, and youth conduct problems. Two hundred thirty-nine youths (ages 12-14 years) and their primary care givers were randomized to either Familias Unidas or Community Practice and assessed pre- and post-intervention. There was a significant difference between Familias Unidas and Community Practice in conduct problems at 3 months (standardized β = -.101, p = .001, effect size = .262). A significant indirect intervention effect was also detected, indicating that Familias Unidas predicted conduct problems at 3 months through parent-adolescent communication at 3 months (standardized β = -.036, p = .016, CI 95% [-.066, -.007], effect size = .265). Familias Unidas was efficacious in reducing conduct problems through improved parent-adolescent communication, relative to Community Practice. Future assessments will determine whether Familias Unidas also has an impact on substance use and sexual risk behaviors at later time points, as demonstrated in past Familias Unidas trials. The short-term effects of the intervention, family engagement, and facilitator skill in the Ecuadorian adaptation of Familias Unidas are promising. This study implies that an intervention developed for Hispanics/Latinos in the USA and culturally adapted and implemented for use by Hispanics/Latinos in a Latin American country can be efficacious in improving family functioning and reducing youth conduct problems.

TRIAL REGISTRATION

MSP-DIS-2015-0055-0, Ministry of Public Health (MSP), Ecuador.

"Home Practice Is the Program": Parents' Practice of Program Skills as Predictors of Outcomes in the New Beginnings Program Effectiveness Trial

An examination of the content and processes of evidence-based programs is critical for empirically evaluating theories about how programs work, the "action theory" of the program (West et al. in American Journal of Community Psychology, 21, 571-605, 1993). The New Beginnings Program (NBP; Wolchik et al., 2007), a parenting-after-divorce preventive intervention, theorizes that program-induced improvements in parenting across three domains: positive relationship quality, effective discipline, and protecting children from interparental conflict, will reduce the negative outcomes that are common among children from divorced families. The process theory is that home practice of program skills related to these parenting domains is the primary mechanism leading to positive change in parenting. This theory was tested using multi-rater data from 477 parents in the intervention condition of an effectiveness trial of the NBP (Sandler et al. 2016a, 2016b). Four research questions were addressed: Does home practice of skills predict change in the associated parenting outcomes targeted by the program? Is the effect above and beyond the influence of attendance at program sessions? What indicators of home practice (i.e., attempts, fidelity, efficacy, and competence) are most predictive of improvements in parenting? Do these indicators predict parenting improvements in underserved subpopulations (i.e., fathers and Latinos)? Structural Equation Modeling analyses indicated that parent-reported efficacy and provider-rated parent competence of home practice predicted improvements in the targeted parenting domains according to both parent and child reports. Moreover, indicators of home practice predicted improvements in parenting for fathers and Latinos, although patterns of effects varied by parenting outcome.

Exposure to a multi-level multi-component childhood obesity prevention community-randomized controlled trial: patterns, determinants, and implications

BACKGROUND

For community interventions to be effective in real-world conditions, participants need to have sufficient exposure to the intervention. It is unclear how the dose and intensity of the intervention differ among study participants in low-income areas. We aimed to understand patterns of exposure to different components of a multi-level multi-component obesity prevention program to inform our future impact analyses.

METHODS

B'more Healthy Communities for Kids (BHCK) was a community-randomized controlled trial implemented in 28 low-income zones in Baltimore in two rounds (waves). Exposure to three different intervention components (corner store/carryout restaurants, social media/text messaging, and youth-led nutrition education) was assessed via post-intervention interviews with 385 low-income urban youths and their caregivers. Exposure scores were generated based on self-reported viewing of BHCK materials (posters, handouts, educational displays, and social media posts) and participating in activities, including taste tests during the intervention. For each intervention component, points were assigned for exposure to study materials and activities, then scaled (0-1 range), yielding an overall BHCK exposure score [youths: mean 1.1 (range 0-7.6 points); caregivers: 1.1 (0-6.7), possible highest score: 13]. Ordered logit regression analyses were used to investigate correlates of youths' and caregivers' exposure level (quartile of exposure).

RESULTS

Mean intervention exposure scores were significantly higher for intervention than comparison youths (mean 1.6 vs 0.5, p < 0.001) and caregivers (mean 1.6 vs 0.6, p < 0.001). However, exposure scores were low in both groups and 10% of the comparison group was moderately exposed to the intervention. For each 1-year increase in age, there was a 33% lower odds of being highly exposed to the intervention (odds ratio 0.77, 95% confidence interval 0.69; 0.88) in the unadjusted and adjusted model controlling for youths' sex and household income.

CONCLUSION

Treatment effects may be attenuated in community-based trials, as participants may be differentially exposed to intervention components and the comparison group may also be exposed. Exposure should be measured to provide context to impact evaluations in multi-level trials. Future analyses linking exposure scores to the outcome should control for potential confounders in the treatment-on-the-treated approach, while recognizing that confounding and selection bias may exist affecting causal inference.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02181010 . Retrospectively registered on 2 July 2014.

Parent-Centered Prevention of Risky Behaviors Among Hispanic Youths in Florida

OBJECTIVES

To evaluate the effectiveness of an evidence-based, parent-centered intervention, Familias Unidas, delivered by nonresearch personnel, in preventing substance use (alcohol, illicit drugs) and sex without a condom among Hispanic adolescents.

METHODS

A randomized controlled trial (n = 746) evaluated the effectiveness of Familias Unidas among Hispanic eighth graders (age range = 12-16 years), relative to prevention as usual, within a public school system. School personnel, including social workers and mental health counselors, were trained to deliver the evidence-based intervention. Participant recruitment, intervention delivery, and follow-up ran from September 2010 through June 2014 in Miami-Dade County, Florida.

RESULTS

Familias Unidas was effective in preventing drug use from increasing and prevented greater increases in sex without a condom 30 months after baseline, relative to prevention as usual. Familias Unidas also had a positive impact on family functioning and parental monitoring of peers at 6 months after baseline.

CONCLUSIONS

This study demonstrated the effectiveness of a parent-centered preventive intervention program in preventing risky behaviors among Hispanic youths. Findings highlight the feasibility of training nonresearch personnel on effectively delivering a manualized intervention in a real-world setting.