Implementation fidelity for promoting the effectiveness of an adolescent sexual health program

Interventions Promoting Condom Use Among Youth: A Systematic Review

In many European and other high-income, Western countries, condom use has been decreasing among youth. A variety of promotional strategies to increase condom use exists. Our systematic review aimed to identify effective elements in interventions aimed at increasing condom use in youth. We searched databases (2010-2021) for intervention studies promoting condom use among youth in Western, high-income countries. The primary outcome was condom use; the secondary outcome was sexually transmitted infection (STI) diagnoses. Effectiveness per intervention was defined based on the percentage of comparisons that showed significant increases in condom use and significant decreases in STIs. We compared the effectiveness of interventions for different participant-, intervention- and methodological characteristics. We included 74 papers describing 85 interventions in the review. Overall, the median intervention effectiveness was 33.3% (interquartile range = 0%-66.7%) for condom use and 0% (interquartile range = 0%-100%) for STI diagnoses. Intervention effectiveness for condom use was significantly higher in interventions tailored towards females and males specifically, compared with interventions applied to both sexes combined. Our findings show the difficulty in designing effective interventions to increase condom use among youth. Interventions aimed at either females or males were more effective in increasing condom use.

Evaluative criteria in practice: Findings from an analysis of evaluations published in Evaluation and Program Planning

BACKGROUND

Evaluative criteria represent values about characteristics that define a successful evaluand. Criteria direct evaluators' lines of inquiry, including how aims are framed, which questions are asked, and what conclusions are reached. Yet, criteria often remain unstated, and little is known about criteria employed in practice.

METHODS

We analyzed 141 evaluations published in Evaluation and Program Planning over four years (2016-2019). Applying a model of criteria domains, we utilized collaborative, interpretive coding to surface and examine the criteria embedded in evaluation aims, questions, and conclusions. We also identified methods used to gather evaluation data.

FINDINGS

Analysis illuminated eight criteria domains evident in the sample and revealed how multiple domains were combined within individual evaluations. We found overlap among data collection methods used to investigate different domains.

CONCLUSIONS

Findings reveal the variety of criteria employed in practice and how evaluators combine criteria to examine multifaceted evaluands. Findings also highlight the need for evaluators to understand how to adapt methods to investigate different criteria domains. This article contributes to the empirical knowledge base about evaluative criteria and identifies revisions to the criteria model.

Monitoring unplanned sexual health curricula adaptations: Using results to improve fidelity and support implementation

Maintaining fidelity to an evidence-based curriculum is important, yet educators may need to adapt to unexpected situations or particular contexts. The purpose of this study is to identify the reasons for unplanned adaptations during implementation of an evidence-based sexual health education program in California. Evaluators reviewed fidelity checklists from the implementation of 571 cohorts for activities with reported unplanned adaptations. Reasons were qualitatively coded and compared across two phases of implementation and by setting. Educators reported 319 unplanned adaptations, affecting 21.5% of the 571 cohorts and 2.9% of 13,782 activities. The most common reasons for unplanned adaptations were due to time management issues, site logistic issues, and to increase participant engagement. Over time, health educators reported fewer unplanned adaptations, particularly those due to time management, resulting in a decrease in the cohorts and activities affected. Adaptations to evidence-based curricula are necessary and often occur during implementation to fit local conditions and populations. Ongoing review of adaptation data provides an opportunity to refine training and technical assistance efforts. Guidance about the types of permitted adaptations and how to anticipate and plan for adaptations for future implementation can ensure fidelity to the core curriculum components and responsiveness to youth participants.

Effects of a Sexual Risk-Reduction Intervention for Teenagers: A Cluster-Randomized Control Trial

This study evaluated the efficacy of the COMPAS program in the short term and 6 months after its application. For the initial sample, 2047 teenagers aged 14–19 years from 14 schools in 11 Colombian cities participated; eight schools were randomly assigned to the experimental condition and six to the control group. The participants completed self-report assessments that evaluated several variables theoretically associated with protective sexual behaviors. In the short term, the experimental group showed increased knowledge about HIV and other STIs, sexual assertiveness, self-efficacy, greater behavioral intention toward condom use, and more favorable attitudes toward HIV and condom use than the control group. After 6 months, most psychological and health variables also showed a significant positive change. In conclusion, the COMPAS program is the first school-based sexuality education program that has been shown to be effective in reducing mediating and behavioral variables associated with sexual risk reduction in Colombia.

Effects as a function of implementation fidelity of a transdiagnostic prevention program in young school-aged children

Super Skills for Life (SSL) is a transdiagnostic prevention program for school-aged children with internalizing problems. The current study aimed to examine the short- and long-term (12-month follow-up) effectiveness of SSL, depending on implementation fidelity. Participants were 123 Spanish-speaking children aged 6-8 years with internalizing symptoms and their parents. High (n = 41) and low fidelity (n = 26) groups were established and compared with a control group (CG) (n = 56). Compared to CG, the high-fidelity group (HFG) achieved better outcomes than the low-fidelity group (LFG) at short and long term, including symptoms of anxiety, depression, and internalizing problems, and also externalizing problems at long-term. The LFG improved key symptoms at short term (depression) and long term (anxiety and depression). Findings suggest that SSL is beneficial even if not delivered at maximum fidelity, although considering the influence of implementation fidelity is critical because the high-fidelity implementation yielded the greatest effects when compared to the CG. This research provides valuable data, analyzing for the first time the influence of fidelity on SSL outcomes in young school-aged children exhibiting internalizing symptoms, while there is still a lack of studies of these characteristics concerning transdiagnostic prevention programs targeting childhood anxiety and depression.

Promoting Adolescent Healthy Relationships (The About Us Program): Protocol for a Randomized Clinical Trial

BACKGROUND

Romantic relationships play a critical role in adolescent development, and by middle adolescence, most young people have been involved in at least one romantic relationship, a context in which most sexual interactions occur. Research suggests adolescents lack positive models and skills related to building healthy relationships.

OBJECTIVE

This project aims to test the impact of an innovative healthy relationships intervention, called About Us, implemented in school-based health centers (SBHCs) in California in a randomized controlled trial.

METHODS

About Us is being tested using a 7-site, 2-group, parallel randomized controlled trial with a treatment versus control allocation ratio of 3:2 to assess the impact of the intervention relative to the standard of care among adolescents aged 14 to 18 years. Adolescents with active parental consent provide study assent at each of the 3 survey time points: baseline, 3 months postintervention, and 9 months postintervention. A stratified randomization procedure was used to ensure balance in key covariates and screening criteria across intervention groups. Through benchmark intent-to-treat analyses, we will examine the primary outcome of this study-the impact of About Us relative to the standard of care 9 months following the end of the intervention on the prevalence of vaginal or anal sex without condoms in the past 3 months. The secondary outcomes are four-fold: what is the impact of About Us relative to the standard of care 3 and 9 months following the end of the intervention, on (1) the prevalence of abstinence from vaginal or anal sex in the past 3 months, (2) composite scores of relationship communication and positive conflict resolution among participants involved in a relationship at baseline, (3) the prevalence of SBHC service use or information receipt in the past 3 months, and (4) composite scores of condom use intentions and attitudes regarding condoms and other birth control? Additionally, as part of our sensitivity analyses, two additional analyses will be implemented: modified intent-to-treat and complete case analysis.

RESULTS

This project (ClinicalTrials.gov #NCT03736876) was funded in 2016 through the Family Youth Services Bureau as part of the Personal Responsibility Education Innovative Strategies program. Baseline data collection took place between February 2018 and March 2020, yielding a total of 5 cohorts and 533 study participants: 316 assigned to treatment and 217 assigned to control. Ongoing follow-up data collection continued through May 2021.

CONCLUSIONS

About Us draws on developmental science to create a contextually and developmentally relevant program that addresses motivation and emotional influences in sexual decision-making. The intervention was designed for implementation within SBHCs, an understudied venue for relationship and sexual health promotion interventions. Unfortunately, COVID-19 pandemic restrictions led to school closures, interrupting ongoing programming, and in-person follow-up data collection, which has affected study attrition.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03736876; https://clinicaltrials.gov/ct2/show/NCT03736876.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30499.

Level of Implementation Fidelity of Youth-Friendly Services in Northwest Ethiopia

Background

Youth-Friendly Services (YFS) is an evidence-based public health intervention aimed to reduce sexual and reproductive health problems among youth. To achieve the desired outcomes, YFS has to be implemented with a high level of fidelity. However, there is an evidence gap in its implementation with fidelity. Hence, the main objective of the study was to describe the level of implementation fidelity of YFS among public health centers in Central Gondar Zone, northwest Ethiopia. Therefore, this study investigated the level of implementation fidelity of YFS among public health centers in Central Gondar Zone, northwest Ethiopia.

Methods

An institutional-based cross-sectional study was conducted from September to December in 2019. A total of 1029 youths, who came to 11 health centers where YFS has been implemented were randomly selected. A validated tool, comprised of 65 Likert scaled items, designed to measure the three dimensions of fidelity was used to collect data. Face to face clients exit interview approach was used to collect the data. Summary statistics were calculated for each fidelity dimension first, and then the overall fidelity of implementation score was computed.

Results

Overall, only 48 (4.7%; 1.6–11.3%) of youth received the YFS with a high level of implementation fidelity. Whereas 770 (74.8%; 57.6–90.5%) and 211 (20.5%; 912.7–31.0%) of youth received the YFS with a medium and low level of implementation fidelity, respectively. Considering each fidelity dimension, 241 (23.4%) youth received the YFS with a high level of adherence, 212 (20.6%) received the YFS with a high level of the structural quality of care, 323 (31.4%) received the YFS with a high level of process quality of care, 508 (49.3%) received the YFS with a high level of outcome quality of care, and 114 (11.1%), received the YFS with a high level of participant responsiveness.

Conclusion

The identified low level of implementation fidelity of YFS indicates the urgent need to strengthen the YFS by the government and programmers. Further studies that can address barriers to the implementation fidelity of Youth-Friendly Services are recommended. In addition, further analysis to know the factors that may influence the fidelity of YFS are recommended.

Sexually Unexperienced Adolescents Benefit the Most From a Sexual Education Program for Adolescents: A Longitudinal Cluster Randomized Controlled Study

Using a longitudinal cluster-randomized controlled design, we examined whether the effects of Competencies for Adolescents with a Healthy Sexuality (COMPAS), an evidence-based sexual health promotion intervention, differ by adolescents' sexual experience. Participants were 699 students aged 14-16, 45.9% were sexually experienced, and assessed in the baseline, posttest, and 12- and 24-month follow-ups. All were recruited from 10 schools that were randomly assigned to the COMPAS program and waiting-list groups (WLG). Using an intent-to-treat analyses, longitudinal changes in psychosocial and behavioral outcomes were explored using generalized estimating equations. Compared to the WLG, COMPAS had a positive impact on six of the seven psychological and behavioral outcomes. Non-sexually experienced reported more favorable HIV-related attitudes, higher condom use intention, lower number of sexual partners, and higher condom use than those sexually experienced. Findings support the importance of implementing sex education actions before adolescents get involved in their first intimate relationships in order to achieve greater impact.

A text mining approach for adapting a school-based sexual health promotion program in Colombia

A common practice among clinical psychologists and other health professionals is the use of school-based sexual health promotion programs as a means for preventing sexually transmitted infections. A fundamental criterion for the designing and adaptation of these programs is the age of their target populations because limited education and language are the most relevant factors that limit the efficacy of these programs. The contribution of this paper consists of assessing both the readability of the written materials that accompany the contents of a Spanish-written school-based sexual health promotion program used in Colombia, as well as the words co-occurrence network structure of its contents. The readability of the evaluated program corresponded to its intended target population aged between 14 and 19, with the schooling of 9-13 years of education. The resulting words co-occurrence network structure of the COMPAS program also mirrored its theoretical content. These results all together are deemed as empirical evidence of the adequacy of the program.

Adaptation of an effective school-based sexual health promotion program for youth in Colombia

RATIONALE

Given the disproportionate impact of HIV and STIs among youth in Latin America, there is a compelling need for effective sex education programs. In particular, Colombia lacks a nationally standardized youth sex education program, despite the fact that 15 to 24-year-olds accounted for the highest incidence and prevalence rates of HIV and STIs in the nation. In an attempt to fill this void, our team adapted COMPAS, a Spanish school-based sexual health promotion intervention, for Colombian adolescents.

OBJECTIVE

This study describes the adaptation process that resulted in a modified version of COMPAS for youth in Colombia.

METHOD

We employed a systematic cultural adaptation process utilizing a mixed methods approach, including intervention adaptation sessions with 100 young adolescents aged 15-19. The process included six steps: 1) consulting international researchers and community stakeholders; 2) capturing the lived experiences of a diverse sample of colombian youth; 3) identifying priorities and areas in need of improvement; 4) integrating the social cognitive theory, information-motivation-behavioral skills model, and an ecological framework for colombian youth; 5) adapting intervention content, activities, and materials; and 6) quantitative evaluation of COMPAS by Colombian youth.

RESULTS

The adapted intervention incorporates elements common to effective youth sex education interventions, including: a solid theoretical foundation, sexual communication skills and social support for protection, and guidance on how to utilize available cultural- and linguistic-appropriate services. In addition, the adapted intervention incorporates cultural and linguistic appropriate content, including an emphasis on tackling machismo to promote risk reduction behaviors.

CONCLUSIONS

The systematic adaptation approach to sexual health intervention for youth can be employed by researchers and community stakeholders in low-resource settings for the promotion of health wellness, linkage to care, and STI and unplanned pregnancy prevention for youth.

Key factors influencing comfort in delivering and receiving sexual health education: Middle school student and teacher perspectives

Sexual health education (SHE) provides students with knowledge and skills to establish healthy relationships, understand sexual development, and prevent risk behaviors; therefore, it is critical to understand how to optimize the delivery and receipt of this education. Using a grounded theory approach, interviews with middle school health education teachers (n=13) and focus groups with students (n=41) were conducted to examine factors that influence perceived comfort delivering and receiving SHE in a public school district. Findings identified key barriers including disruptive behavior, insufficient time, and lack of dedicated classrooms. Some key facilitators to comfort included professional development and establishing ground rules.