Study Protocol: Multi-level Determinants of Implementation and Sustainment in the Education Sector

Evidence-based programs (EBPs) delivered in elementary schools show great promise in reducing risk for emotional and behavioral disorders (EBDs). However, efforts to sustain EBPs in school face barriers. Improving EBP sustainment thus represents a priority, but little research exists to inform the development of sustainment strategies. To address this gap, the Sustaining Evidenced-Based Innovations through Multi-level Implementation Constructs (SEISMIC) project will: (a) Determine if malleable individual, intervention, and organizational factors predict EBP treatment fidelity and modifications during implementation, sustainment, or both; (b) Assess the impact of EBP fidelity and modifications on child outcomes during implementation and sustainment; and (c) Explore the mechanisms through which individual, intervention, and organizational factors influence sustainment outcomes. This protocol paper describes SEISMIC, which builds upon a federally-funded RCT evaluating BEST in CLASS, a teacher-delivered program for K-3rd grade children at risk for EBDs. The sample will include 96 teachers, 384 children, and 12 elementary schools. A multi-level, interrupted time series design will be used to examine the relationship between baseline factors, treatment fidelity, modifications, and child outcomes, followed by a mixed-method approach to elucidate the mechanisms that influence sustainment outcomes. Findings will be used to create a strategy to improve EBP sustainment in schools.

Evaluation of the Implementation of a 25-Year Outdoor School Ground Smoking Ban: A Qualitative Interview Study With Implications for Prevention Practise

Introduction: Tobacco use, often initiated in younger ages, is a serious health challenge worldwide. In Sweden, smoking has been prohibited on school grounds since 1994. Municipal environmental and health inspectors control the compliance of the ban. Nevertheless, the enforcement and maintenance of the ban are inadequate. The aim of the current study was to identify facilitators, barriers, and the potential for improved implementation of a 25-year outdoor school ground smoking ban in upper secondary schools.

Materials and Methods: A process evaluation was conducted using semi-structured interviews with principals in upper secondary schools, local environmental and health inspectors, and local politicians (n = 30) in Stockholm County, with purposive sampling for informant recruitment. A qualitative content analysis of the transcribed interviews was performed.

Results: Three main categories and 10 subcategories were generated from the interviews, revealing facilitators, barriers, and the potential for improvement of the implementation of the ban. A prominent facilitator of the ban was informed and engaged principals and inspectors. Prominent barriers were conflicting goals governing the schools, which reduce staffs' motivation to maintain the ban, unclear school ground boundaries, and lack of resources. Potential for improvement was found in a new tobacco act with an extended ban on smoking at school entrances, extended support for schools and staff to strictly enforce the ban, and a continued denormalisation of smoking in society.

Conclusion: To achieve effective implementation of outdoor school ground smoking bans in upper secondary schools, authorities need to address conflicts between different goals governing the schools and give necessary support to the staff to strictly enforce the ban. Policies on smoke-free working hours in the municipalities along with tobacco restrictive policies in the surrounding society may increase the possibility to maintain the smoking ban in upper secondary school grounds.

Bahamas National Implementation Project: Proposal for Sustainability of an Evidence-based HIV Prevention Intervention in a School Setting

BACKGROUND

Sustained implementation of school-based prevention programs is low. Effective strategies are needed to enhance both high-level implementation fidelity and sustainability of prevention programs.

OBJECTIVE

This proposed study aims to determine if the provision of either biweekly monitoring and feedback and site-based assistance and mentorship or both to at-risk and moderate-performing teachers with monitoring through an enhanced decision-making platform by the Ministry of Education (MOE) and Ministry of Health (MOH) based on the real-time implementation data will increase national implementation fidelity and result in sustained implementation over time.

METHODS

This study will target government schools including 200 grade 6 teachers in 80 primary schools and 100 junior/middle high school teachers (and their classes) on 12 Bahamian islands. Teacher and school coordinator training will be conducted by the MOE in year 1, followed by an optimization trial among teachers in the capital island. Informed by these results, an implementation intervention will be conducted to train using different levels of educational intensity all at-risk and moderate-performing teachers. Subsequently selected training and implementation strategies will be evaluated for the national implementation of Focus on Youth in the Caribbean and Caribbean Informed Parents and Children Together in years 2 to 5.

RESULTS

It is hypothesized that a more intensive training and supervision program for at-risk and moderate-performing teachers will enhance their implementation fidelity to the average level of the high-performing group (85%), an HIV prevention program delivered at the national level can be implemented with fidelity in grade 6 and sustained over time (monitored annually), and student outcomes will continue to be highly correlated with implementation fidelity and be sustained over time (assessed annually through grade 9). The proposed study is funded by the National Institute of Child Health and Human Development from August 1, 2018, through May 31, 2023.

CONCLUSIONS

The study will explore several theory-driven implementation strategies to increase sustained teacher implementation fidelity and thereby increase the general public health impact of evidence-based interventions. The proposed project has potential to make significant contributions to advancing school-based HIV prevention research and implementation science and serve as a global model for the Fast Track strategy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/14816.

Three-year maintenance of a teacher-led programme targeting motor competence in early adolescent girls

Motor competence (MC) in youth is associated with positive health outcomes, yet few achieve their developmental capability. Although numerous MC studies address initial intervention effectiveness, fewer consider intervention sustainability. This study aimed to investigate whether teachers continued to implement an effective MC programme targeting girls (mean age 12.4 ± 0.3 years), three years post-intervention. Ongoing implementation was examined using three domains of the UK Medical Research Council's framework: (i) implementation, (ii) mechanisms of impact, and (iii) context. Teachers (n = 18) completed self-report questionnaires and participated in focus group discussions (FGs). Descriptive statistics analysed questionnaires. FGs were audio recorded, transcribed verbatim and analysed in NVivo 11 using a framework approach. All teachers had continued to implement the programme, or elements thereof, three years post-intervention. The intervention structure, in particular alignment to the physical education context and curriculum, most notably influenced ongoing programme implementation. Improvement, both teacher practice and student performance, emerged as a driver of sustained impact. The programme demand appeared to be the most important facilitator of programme sustainability. Adaptations made to enhance contextual fit of the programme, post-intervention, extended the programme reach. Framed by implementation science, these findings provide valuable insight into programme sustainability and potential scalability.

Understanding the dynamic interinfluences of implementation processes: An illustration by multiple case studies

Many dropout prevention programs have been developed and validated in the past decades. Yet, little is known about the contextual factors influencing the implementation of these programs. Implementation processes, such as school principal leadership and governmental funding, have been identified for their influence on program implementation, but the mutual or dynamic influence of these processes is yet to be understood. This study examines the processes involved in the implementation of Check & Connect (C&C), a well-established targeted dropout prevention program validated in several countries that aims at promoting the development of a significant relationship between at-risk students and a mentor as a way to prevent school dropout. Semi-structured interviews were conducted with 12 mentors and coordinators directly involved in C&C implementation. Analyses were conducted in two subsequent steps: thematic analyses first helped identify implementation processes described by respondents, and then synthetic case studies allowed us to build the implementation stories of distinct sites. This last step was conducted using the Planned Change Framework. This framework helped us to understand the complex dynamics of implementation processes in each site, which were associated with previously identified program outcomes, beyond implementation fidelity. Implications for future implementations of evidence-based programs in the school setting are discussed.

Building Schools' Readiness to Implement a Comprehensive Approach to School Safety

Research consistently finds that a comprehensive approach to school safety, which integrates the best scientific evidence and solid implementation strategies, offers the greatest potential for preventing youth violence and promoting mental and behavioral health. However, schools and communities encounter enormous challenges in articulating, synthesizing, and implementing all the complex aspects of a comprehensive approach to school safety. This paper aims to bridge the gap between scientific evidence and the application of that evidence in schools and communities by defining the key components of a comprehensive approach to school safety and describing how schools can assess their readiness to implement a comprehensive approach. We use readiness and implementation data from the Safe Communities Safe Schools project to illustrate these challenges and solutions. Our findings suggest that (1) readiness assessment can be combined with feasibility meetings to inform school selection for implementation of a comprehensive approach to school safety and (2) intentionally addressing readiness barriers as part of a comprehensive approach may lead to improvements in readiness (motivation and capacity) to effectively implement a comprehensive approach to school safety.

Sustainability of outdoor school ground smoking bans at secondary schools: a mixed-method study

Background

Although increasing numbers of countries are implementing outdoor school ground smoking bans at secondary schools, less attention is paid to the post-implementation period even though sustainability of a policy is essential for long-term effectiveness. Therefore, this study assesses the level of sustainability and examines perceived barriers/facilitators related to the sustainability of an outdoor school ground smoking ban at secondary schools.

Methods

A mixed-method design was used with a sequential explanatory approach. In phase I, 438 online surveys were conducted and in phase II, 15 semi-structured interviews were obtained from directors of relevant schools. ANOVA (phase I) and a thematic approach (phase II) were used to analyze data.

Results

Level of sustainability of an outdoor school ground smoking ban was high at the 48% Dutch schools with an outdoor smoking ban. Furthermore, school size was significantly associated with sustainability. The perceived barriers/facilitators fell into three categories: (i) smoking ban implementation factors (side-effects, enforcement, communication, guidelines and collaboration), (ii) school factors (physical environment, school culture, education type and school policy) and (iii) community environment factors (legislation and social environment).

Conclusions

Internationally, the spread of outdoor school ground smoking bans could be further promoted. Once implemented, the ban has become ‘normal’ practice and investments tend to endure. Moreover, involvement of all staff is important for sustainability as they function as role models, have an interrelationship with students, and share responsibility for enforcement. These findings are promising for the sustainability of future tobacco control initiatives to further protect against the morbidity/mortality associated with smoking.

Variable Implementation of Sexuality Education in Three Nigerian States

In 2003, Nigeria adopted the Family Life and HIV Education (FLHE) sexuality education curriculum. Our analysis interrogates variation in sub-national implementation. We conducted 52 interviews with persons knowledgeable about the curriculum in three states-Kano, Lagos, and Niger-and reviewed publications on FLHE. In Kano, the socio-cultural context impeded implementation, but the persistence of innovative local champions resulted in some success. In Lagos, the cosmopolitan context, effective champions, funding by international donors, and a receptive government bureaucracy led to successful implementation. In Niger, despite a relatively conservative socio-cultural context, state bureaucratic bottlenecks overwhelmed proponents' efforts. In summary, the interaction of socio-cultural context, domestic champions, adaptive capacity of state bureaucracies, and international funders explains variable implementation of FLHE. The Nigerian experience highlights the need for sexuality education proponents to anticipate and prepare for local opposition and bureaucratic barriers.

Intent to sustain use of a mental health innovation by school providers: What matters most?

Despite innovations being routinely introduced in schools to support the mental health of students, few are successfully maintained over time. This study explores the role of innovation characteristics, individual attitudes and skills, and organizational factors in school providers' decisions to continue use of Centervention, a technology-based tool that supports implementation of evidence-based mental health interventions (EBIs). Data were collected from 44 providers through online surveys following use of Centervention over a one-year period. When considered with individual and organizational factors, experience with Centervention (usability, usefulness, and satisfaction) was found to be the most influential predictor of intent to sustain use. Results reinforce the importance of (1) differentiating between factors that predict initial adoption vs. those that enable sustainability and (2) tailoring sustainability decision models to the nature of the innovation. They also support the need to incorporate strategies to enhance provider experience during implementation of an innovation.

ASPiH standards for simulation-based education: process of consultation, design and implementation

There is widespread enthusiasm and emerging evidence of the efficacy of simulation-based education (SBE) but the full potential of SBE has not been explored. The Association for Simulated Practice in Healthcare (ASPiH) is a not-for-profit membership association with members from healthcare, education and patient safety background. ASPiH’s National Simulation Development Project in 2012 identified the lack of standardisation in the approach to SBE with failure to adopt best practice in design and delivery of SBE programmes. ASPiH created a standards project team in 2015 to address this need. The article describes the iterative process modelled on implementation science framework, spread over six stages and 2 years that resulted in the creation of the standards. The consultation process supported by Health Education England resulted in a unique document that was driven by front line providers while also having strong foundations in evidence base. The final ASPiH document consisting of 21 standards for SBE has been extensively mapped to regulatory and professional bodies in the UK and abroad ensuring that the document is relevant to a wide healthcare audience. Underpinning the standards is a detailed guidance document that summarises the key literature evidence to support the standard statements. It is envisaged the standards will be widely used by the simulation community for quality assurance and improving the standard of SBE delivered.

A Health Care Project Management Office's Strategies for Continual Change and Continuous Improvement

Health care organizations need project and change management support in order to achieve successful transformations. A project management office (PMO) helps support the organizations through their transformations along with increasing their capabilities in project and change management. The aim of the present study was to extend understanding of the continuous improvement mechanisms used by PMOs and to describe PMO's strategies for continual change and continuous improvement in the context of major transformation in health care. This study is a descriptive case study design with interviews conducted from October to December 2015 with PMO's members (3 managers and 1 director) and 3 clients working with the PMO after a major redevelopment project ended (transition to the new facility). Participants suggested a number of elements including carefully selecting the members of the PMO, having a clear mandate for the PMO, having a method and a discipline at the same time as allowing openness and flexibility, clearly prioritizing projects, optimizing collaboration, planning for everything the PMO will need, not overlooking organizational culture, and retaining the existing support model. This study presents a number of factors ensuring the sustainability of changes.

Practitioner Review: Empirical evolution of youth psychotherapy toward transdiagnostic approaches

BACKGROUND

Psychotherapy for children and adolescents (herein, 'youths') has grown more precise and focused over the decades, shifting toward empirically supported treatments standardized via therapist manuals. The manuals have increasingly emphasized precise targeting of single disorders or problems, or homogenous clusters. These focal treatments represent a valuable advance, with intervention benefit documented in hundreds of studies. However, relatively few of these treatments are widely used in everyday clinical practice, and their level of benefit may not be ideal, particularly in practice contexts and when compared to usual clinical care.

THESIS

These limitations may be due, in part, to a mismatch between focal treatment design and the young people treated in real-world clinical care, who are diagnostically heterogeneous, and very frequently present with comorbidity. Improved fit may be achieved via transdiagnostic treatment approaches designed to address multiple disorders and problems, if these approaches can retain the benefits of manualization and the substantive clinical strength that has generated empirical support to date.

SCOPE

Here we review the evolution of empirically-based youth psychotherapy from focal treatment manuals toward transdiagnostic approaches, and we describe and illustrate three transdiagnostic treatment strategies: (a) a core dysfunction approach, (b) a common elements and modular design approach, and (c) a principle-guided approach.

CLINICAL APPLICATIONS

We complement research findings with a clinical perspective based on our use of manual-guided transdiagnostic intervention in clinical care settings, and we propose directions for research and practice.

Identifying and Predicting Distinct Patterns of Implementation in a School-Wide Behavior Support Framework

The purpose of this study was to examine the extent to which distinct patterns of fidelity of implementation emerged for 5331 schools over a 5-year course of implementing school-wide positive behavioral interventions and supports (SWPBIS). We used latent class analysis to classify schools based on their likelihood of implementing SWPBIS with fidelity each year, then assessed school and district predictors of classifications. A four-class solution fit the model well, with two patterns of sustained implementation (Sustainers and Slow Starters) and two patterns of practice abandonment (Late Abandoners and Rapid Abandoners). Significant predictors of group membership included grade levels served, enrollment, proportion of schools implementing SWPBIS in the district ("critical mass"), and size of the implementation cohort ("community of practice"). Elementary schools, larger schools, schools in districts with more schools already implementing SWPBIS, and those starting within a larger initial district cohort were more likely to be in the sustaining classes. Results are discussed in terms of understanding patterns of implementation in schools to enhance sustained implementation of school practices.

Factors that predict financial sustainability of community coalitions: five years of findings from the PROSPER partnership project

This study is a longitudinal investigation of the Promoting School-community-university Partnerships to Enhance Resilience (PROSPER) partnership model designed to evaluate the level of sustainability funding by community prevention teams, including which factors impact teams' generation of sustainable funding. Community teams were responsible for choosing, implementing with quality, and sustaining evidence-based programs (EBPs) intended to reduce substance misuse and promote positive youth and family development. Fourteen US rural communities and small towns were studied. Data were collected from PROSPER community team members (N = 164) and prevention coordinators (N = 10) over a 5-year period. Global and specific aspects of team functioning were assessed over six waves. Outcome measures were the total funds (cash and in-kind) raised to implement prevention programs. All 14 community teams were sustained for the first 5 years. However, there was substantial variability in the amount of funds raised, and these differences were predicted by earlier and concurrent team functioning and by team sustainability planning. Given the sufficient infrastructure and ongoing technical assistance provided by the PROSPER partnership model, local sustainability of EBPs is achievable.

Teachers' patterns of implementation of an evidence-based intervention and their impact on student outcomes: results from a nationwide dissemination over 24-months follow-up

More information is needed about factors influencing real-life implementation and program impact of interventions effective in controlled study conditions. Ongoing national implementation of an evidence-based HIV prevention program targeting grade 6 students in The Bahamas offers the opportunity to examine patterns of implementation and relate them to student outcomes. Data were collected from 208 grade 6 teachers, 75 grade 7 teachers and 4411 grade 6 students followed over 2 years. Mixed-effects modeling analysis examined the association of teachers' patterns of implementation with student outcomes. High quality program implementation in grade 6 (high implementation dosage and fidelity) was significantly related to student outcomes six and 18 months post-intervention. Quality of implementation of the booster session in grade 7 was also significantly related to student outcomes in grade 7. Quality of delivery of the brief booster session a year after initial implementation is important in maintaining or resetting the student outcome trajectory.

Issues in implementing a comprehensive intervention for public school children with autism spectrum disorders

Many students with autism spectrum disorders (ASD) are educated separately from their typically developing peers, while others are placed in inclusive classes but without supports that would help them benefit from less restrictive placements. The needs of students with ASD who are in inclusive settings are often not planned for or met appropriately, resulting in continuing problems and movement to increasingly restrictive environments or private placements. There is a critical need for school models to fill the gap in appropriate services for this population of children with ASD. These models should include those that are inclusive and academically challenging, that can be implemented by many school districts, and that are responsive to the unique combination of strengths and deficits in these students. In the current article, the authors describe the development and core components of the model, and implementation of the ASD Nest program in public schools in New York City.

Factors influencing implementation dose and fidelity thereof and related student outcomes of an evidence-based national HIV prevention program

Background

Teachers’ implementation of evidence-based prevention programs in schools is inconsistent. Using data gathered from the national implementation among grade six students in The Bahamas of an evidence-based HIV intervention [Focus on Youth in the Caribbean (FOYC)], this study examines differences in the degree of implementation (“dose”) and adherence to the core activities (“fidelity of implementation”) by teachers according to theoretically and historically relevant teachers’ characteristics, attitudes, and experiences pre-intervention and post-intervention. The relationship of implementation dose and implementation fidelity is assessed according to student outcomes.

Methods

Beginning in 2008, the Bahamian Ministry of Education (MOE) included FOYC in the grade six curriculum nationwide. Consistent with standard practice, teachers were offered MOE training workshops in FOYC prior to delivery. The MOE conducted an anonymous curricular assessment among the grade six students at the beginning and end of the school year. Teachers agreeing to participate in the research component were asked to complete a pre-implementation and post-implementation assessment of attitudes and prior experiences.

Results

Teachers taught 15.6 out of 30 core activities, 24 out of the 46 total activities, and 4.6 out of 8 sessions on average. Three teachers’ implementation groups were identified: 1) High Implementation Group (31.7% of the teachers), characterized by high levels of implementation dose and fidelity of implementation; 2) Moderate Implementation Group (52.8%), showing moderate levels of implementation dose but high levels of fidelity of implementation; and 3) Low Implementation Group (15.6%), with low levels of implementation dose and fidelity of implementation. Low Implementation Group teachers compared to teachers in the two higher performing groups had less training in interactive teaching, limited prior exposure to the FOYC curriculum, incomplete attendance at FOYC training workshops, and low levels of comfort in teaching FOYC lessons. Students taught by teachers in the Low Implementation Group demonstrated poorer outcomes relevant to the four student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection if they were to have sex).

Conclusions

Both implementation dose and implementation fidelity are related to student outcomes. Teachers at risk for limited implementation can be identified pre-intervention, thus opening the possibility for focused pre-intervention training.

Implementing the foundations of learning project: considerations for preschool intervention research

While studies have documented the importance of strong implementation in intervention studies (e.g., see Durlak & Dupre, 2008 ), more information is needed about how to ensure strong fidelity and quality of program implementation when delivering interventions under "real world conditions" and on a large scale. In this article, key lessons in implementing a demonstration and evaluation project known as the Foundations of Learning (FOL) demonstration are presented. Our discussion highlights several key components to the success of the project, including the building of effective coalitions before, and during, the delivery of the intervention to support the implementation process, as well as intensive, collaborative, and multilayered technical assistance provided as the intervention was delivered. Key lessons learned over the course of this project represent some that are highly consistent with prior research on this topic, as well as some that are unique, thus representing new areas for exploration in this burgeoning area of study.

Concepts and strategies on how to train and motivate teachers to implement a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study

The key person for the implementation of kindergarten-based behavioural interventions is the kindergarten teacher. When conducting intervention studies in kindergartens, training sessions are needed to train and motivate kindergarten teachers for programme implementation. This paper presents the systematic development of the teachers' trainings executed in the ToyBox-intervention - a kindergarten-based and family-involved obesity prevention programme for children aged 4-6. Based on concepts for the education of kindergarten teachers, on general strategies for successful programme implementation and on the ToyBox programme-specific requirements, the aims of the teachers' trainings were defined and an overall concept was deduced. Regarding the concept for the ToyBox teachers' training sessions, it is concluded that the training modules should focus on presenting information on the practical implementation of the intervention. Furthermore, these modules should also include self-efficacy enhancing components and should give kindergarten teachers opportunities to share experiences. Regarding the didactic methods applied in the ToyBox teachers' training sessions, constructivist learning approaches that facilitate active participation, reflective thinking and personal involvement were implemented. Emphasis was put not only on the content but especially on the didactic methods of teachers' trainings in order to enhance devotion to, and quality and sustainability of the ToyBox-intervention.

Guided by Theory, Informed by Practice: Training and Support for the Good Behavior Game, a Classroom-based Behavior Management Strategy

Moving evidence-based practices for classroom behavior management into real-world settings is a high priority for education and public health. This paper describes the development and use of a model of training and support for the Good Behavior Game (GBG), one of the few preventive interventions shown to have positive outcomes for elementary school children lasting through to young adulthood, ages 19-21, including reductions in the use of drugs and alcohol, school-based mental health services, and suicide ideation and attempts. We first describe the conceptual framework guiding the development of the model of training and support. Data on implementation of the model, from an ongoing trial of GBG being conducted in partnership with the Houston Independent School District, are then presented. We end with a discussion of the lessons learned and the implications for the next stage of research and practice.

The Ecology of Sustainable Implementation: Reflection on a 10-Year Case History Illustration

The primary aim of this paper is to illustrate the strategic and ecological nature of implementation. The ultimate aim of implementation is not dissemination but sustainability beyond the implementation effort. A case study is utilized to illustrate these broad and long-term perspectives of sustainable implementation based on qualitative analyses of a 10-year implementation effort. The purveyors aimed to develop selective community prevention services for children in families burdened by parental psychiatric or addictive problems. Services were gradually disseminated to 23 sites serving 40 municipalities by 2013. Up to 2013, only one site terminated services after initial implementation. Although many sites suspended services for shorter periods, services are still offered at 22 sites. This case analysis is based on project reports, user evaluations, practitioner interviews, and service statistics. The paper focuses on the analyses and strategies utilized to cope with quality decay and setbacks as well as progress and success in disseminating and sustaining the services and their quality. Low-cost multilevel strategies to implement services at the community level were organized by a prevention unit in child psychiatry, supervised by a university department (purveyors). The purveyors were also involved in national and international collaboration and development. Multilevel strategies included manualized intervention, in-practice training methods, organizational responsibility, media strategies, service evaluation, staff motivation maintenance, quality assurance, and proposals for new law regulations. These case history aspects will be discussed in relation to the implementation literature, focusing on possible applicability across settings.

Tier II Interventions within the Framework of School-Wide Positive Behavior Support: Essential Features for Design, Implementation, and Maintenance

To meet the complex social behavioral and academic needs of all students, schools benefit from having available multiple evidence-based interventions of varying intensity. School-wide positive behavior support provides a framework within which a continuum of evidence-based interventions can be implemented in a school. This framework includes three levels or tiers of intervention; Tier I (primary or universal), Tier II (secondary or targeted), and Tier III (tertiary or individualized) supports. In this paper we review the logic behind school-wide positive behavior support and then focus on Tier II interventions, as this level of support has received the least attention in the literature. We delineate the key features of Tier II interventions as implemented within school-wide positive behavior support, provide guidelines for matching Tier II interventions to school and student needs, and describe how schools plan for implementation and maintenance of selected interventions.

The effect of the PROSPER partnership model on cultivating local stakeholder knowledge of evidence-based programs: a five-year longitudinal study of 28 communities

A substantial challenge in improving public health is how to facilitate the local adoption of evidence-based interventions (EBIs). To do so, an important step is to build local stakeholders' knowledge and decision-making skills regarding the adoption and implementation of EBIs. One EBI delivery system, called PROSPER (PROmoting School-community-university Partnerships to Enhance Resilience), has effectively mobilized community prevention efforts, implemented prevention programming with quality, and consequently decreased youth substance abuse. While these results are encouraging, another objective is to increase local stakeholder knowledge of best practices for adoption, implementation and evaluation of EBIs. Using a mixed methods approach, we assessed local stakeholder knowledge of these best practices over 5 years, in 28 intervention and control communities. Results indicated that the PROSPER partnership model led to significant increases in expert knowledge regarding the selection, implementation, and evaluation of evidence-based interventions. Findings illustrate the limited programming knowledge possessed by members of local prevention efforts, the difficulty of complete knowledge transfer, and highlight one method for cultivating that knowledge.

Enhancing the Translation of Physical Activity Interventions in Afterschool Programs

Afterschool programs (3-6 pm, ASPs) represent a promising approach to promote physical activity (PA) and are positioned to make a substantial contribution to children’s overall daily PA. This article synthesizes both descriptive and intervention focused efforts aimed at describing/increasing PA within the ASP setting and outlines future directions for research. ASPs provide anywhere from 8 to 24 minutes of moderate-to-vigorous PA daily, with children accumulating between 2600 and 3200 steps per day. State and national organizations have developed policies related to PA in ASPs, but the limited available evidence indicates that ASPs are far from meeting PA policy goals. A total of 17 ASP PA intervention studies have been conducted, more than half (9/17) within ASPs that were initiated and developed by researchers. Based on the review of evidence, key strategies to increase PA include high-quality professional development training, allocating time in the ASP schedule for children to engage in sufficient amounts of PA, and tailoring the intervention to local conditions. Future directions should focus on evaluating these key strategies, conducting descriptive studies of common ASP characteristics nationally and their influence on children’s PA, evaluation/refinement of existing ASP PA curricula, cost-effectiveness of interventions, and identification of feasible PA policy goals.

Translational Research in South Africa: Evaluating Implementation Quality Using a Factorial Design

BACKGROUND: HealthWise South Africa: Life Skills for Adolescents (HW) is an evidence-based substance use and sexual risk prevention program that emphasizes the positive use of leisure time. Since 2000, this program has evolved from pilot testing through an efficacy trial involving over 7,000 youth in the Cape Town area. Beginning in 2011, through 2015, we are undertaking a new study that expands HW to all schools in the Metro South Education District. OBJECTIVE: This paper describes a research study designed in partnership with our South African collaborators that examines three factors hypothesized to affect the quality and fidelity of HW implementation: enhanced teacher training; teacher support, structure and supervision; and enhanced school environment. METHODS: Teachers and students from 56 schools in the Cape Town area will participate in this study. Teacher observations are the primary means of collecting data on factors affecting implementation quality. These factors address the practical concerns of teachers and schools related to likelihood of use and cost-effectiveness, and are hypothesized to be "active ingredients" related to high-quality program implementation in real-world settings. An innovative factorial experimental design was chosen to enable estimation of the individual effect of each of the three factors. RESULTS: Because this paper describes the conceptualization of our study, results are not yet available. CONCLUSIONS: The results of this study may have both substantive and methodological implications for advancing Type 2 translational research.

INTEGRATED MODELS OF SCHOOL-BASED PREVENTION: LOGIC AND THEORY

School-based prevention programs can positively impact a range of social, emotional, and behavioral outcomes. Yet the current climate of accountability pressures schools to restrict activities that are not perceived as part of the core curriculum. Building on models from public health and prevention science, we describe an integrated approach to school-based prevention. These models leverage the most effective structural and content components of social-emotional and behavioral health prevention interventions. Integrated interventions are expected to have additive and synergistic effects that result in greater impacts on multiple student outcomes. Integrated programs are also expected to be more efficient to deliver, easier to implement with high quality and integrity, and more sustainable. We provide a detailed example of the process through which the PAX-Good Behavior Game and the Promoting Alternative Thinking Strategies (PATHS) curriculum were integrated into the PATHS to PAX model. Implications for future research are proposed.

Study protocol for a group randomized controlled trial of a classroom-based intervention aimed at preventing early risk factors for drug abuse: integrating effectiveness and implementation research

Background

While a number of preventive interventions delivered within schools have shown both short-term and long-term impact in epidemiologically based randomized field trials, programs are not often sustained with high-quality implementation over time. This study was designed to support two purposes. The first purpose was to test the effectiveness of a universal classroom-based intervention, the Whole Day First Grade Program (WD), aimed at two early antecedents to drug abuse and other problem behaviors, namely, aggressive, disruptive behavior and poor academic achievement. The second purpose--the focus of this paper--was to examine the utility of a multilevel structure to support high levels of implementation during the effectiveness trial, to sustain WD practices across additional years, and to train additional teachers in WD practices.

Methods

The WD intervention integrated three components, each previously tested separately: classroom behavior management; instruction, specifically reading; and family-classroom partnerships around behavior and learning. Teachers and students in 12 schools were randomly assigned to receive either the WD intervention or the standard first-grade program of the school system (SC). Three consecutive cohorts of first graders were randomized within schools to WD or SC classrooms and followed through the end of third grade to test the effectiveness of the WD intervention. Teacher practices were assessed over three years to examine the utility of the multilevel structure to support sustainability and scaling-up.

Discussion

The design employed in this trial appears to have considerable utility to provide data on WD effectiveness and to inform the field with regard to structures required to move evidence-based programs into practice.

Trial Registration

Clinical Trials Registration Number: NCT00257088

Influence of funding cuts on Texas school tobacco programs

BACKGROUND

Following the Master Settlement Agreement, state tobacco prevention spending peaked in 2002, but has subsequently been diminishing annually. This study compared the influence of 2004 Texas tobacco program budget cuts on school practices a year after funding loss.

METHODS

Three school groups were compared: continuously funded for a 2-year minimum (n = 109), funded but discontinued (n = 123), and never funded (n = 70). Among the 123 schools with discontinued funding, differences were examined based on funding cut decision level (state or local). Written responses to surveys based on the Centers for Disease Control and Prevention (CDC) School Health Education Profile Tobacco Module were received from 49% of health coordinators and 58% of principals.

RESULTS

Principals and health coordinators from continuously funded schools reported more 1) tobacco instrunctional activities; 2) teacher training; 3) student cessation support; 4) program leadership; 5) a district advocate; 6) interest in tobacco use prevention education; 7) use of evidence-based programs and CDC-recommended teaching methods; 8) involvement of school staff; 9) student tobacco cessation programs at school and community; 10) family involvement; and 11) staff development funding. Previously funded schools approached profiles of those never funded. Few differences were noted among schools with funding loss due to state or local decisions.

CONCLUSION

The continuously funded schools consistently were better positioned to positively reach their students with effective tobacco programs. Funding reductions were associated with rapid reductions in programming. Results emphasize the need for early programmatic initiation of capacity building skill development to ensure implementation and retention of health programs during fiscally challenging circumstances.

Preventive interventions addressing underage drinking: state of the evidence and steps toward public health impact

The epidemiological features of underage drinking and evidence of its social, health, and economic consequences suggest compelling reasons for the development and dissemination of effective preventive interventions. To clarify the nature and extent of the current evidence base on preventive interventions addressing underage drinking, a review of the literature was conducted through extensive searches of the research literature on outcome evaluations, existing reviews of this body of outcome research (N = 25), and summary reports of evidence on specific interventions. More than 400 interventions were identified and screened, and the evidence for 127 was reviewed. Criteria for the evaluation of evidence were established for intervention studies with alcohol-specific outcome measures for 3 developmental periods (< 10, 10-15, and 16 to > or = 20 years of age). Ultimately, 12 interventions met criteria for "most promising" evidence and 29 met criteria for "mixed or emerging" evidence. Conducting this review revealed clear advances in the number of evidence-based interventions available and the quality of outcome research; however, much work remains to achieve greater public health impact through evidence-based interventions. This work should consider (1) the great need for intervention research related to understudied developmental phases, intervention domains (eg, family, school, community, and media), and populations (eg, early tweens, late teens, young adults not attending college, and nonmajority populations); (2) the critical importance of addressing key issues in research design and methods (eg, limited longitudinal studies, replication studies, and dissemination research); and (3) the need for improved consistency in application of evidence and reporting standards. Finally, we recommend the application of emerging consumer-oriented and community-participatory models for intervention development and research, designed to increase the likelihood of "real-world" public health impact through improved translation of intervention science into practice.

Promoting Positive Youth Development

The articles in this special issue report the efforts of the Miami Youth Development Project (YDP), a community-supported positive youth development program of outreach research that draws on a developmental intervention science (DIS) perspective (i.e., a fusion of the developmental and intervention science literatures). These reports illustrate how the application of DIS outreach research contributes to knowledge of human development at all levels (practical as well as methodological, theoretical, and metatheoretical). Consistent with a DIS outreach research approach, YDP is committed to the use of descriptive and explanatory knowledge about changes within human systems that occur across the life span in the development of evidence-based individual and institutional longitudinal change intervention strategies in promoting long-term developmental change. The evolution of the Miami YDP illustrates the value of DIS outreach research “in action.”

School climate and implementation of a preventive intervention

Although there has been wide dissemination of research-based psychosocial prevention programs, a similarly strong research base to guide program implementation has been lacking. Program implementation has been particularly difficult for schools, due partly to insufficient understanding of how school ecologies interact with these programs. This study examined the effects of multiple dimensions of school climate on level and rate of change in implementation of a violence prevention intervention across three school years. Using multi-level modeling, the study found that teacher-reported support between staff and among teachers and students predicted higher average levels of implementation. Teacher-reported administrative leadership predicted greater growth in implementation across 3 years. Findings offer implications for an ecological model of program implementation that considers school-level contextual effects on adoption and sustainability of new programs in schools.

Evaluating school capacity to implement new programs

An eight-factor survey-based Bayesian model (Bridge-It) for assessing school capacity to implement health and education programs was tested in secondary analyses of data from 47 schools in the Texas Tobacco Prevention Initiative (TTPI). Bridge-It was used during the pre-implementation phase and again at mid-course of the TTPI 2 years later. Achieved implementation status was evaluated in follow-up almost 4 years after the start of the TTPI. The Bridge-It score aggregated across all eight of the capacity factors predicted both quality of adherence to the Guidelines for School Programs to Prevent Tobacco Use and Addiction and quantity of implementing activity. The school-based leadership factor was an independent predictor of quality of adherence whereas the facilitation processes factor predicted quantity of implementing activity. Integration of Bridge-It, or comparable multi-attribute tools, into the planning and evaluation of school-centered programs can increase understanding of factors that influence implementation and provide guidance for capacity building.

Great minds don't always think alike: the challenges of conducting substance abuse prevention research in public schools

Prevention researchers and school personnel lack a common understanding concerning the opportunities and burdens of school-based drug prevention research. In this article, we review issues related to researching substance abuse prevention programs in school settings, and assess challenges related to recruitment, communication, research design, surveying, and ensuring program fidelity. We conclude that before any school is enrolled, there must be a mutual understanding as to the nature and extent of the study's requirements and what adjustments a school will have to make to support a successful collaboration. Further, researchers must understand that schools' responsibilities for preparing students to perform well on academic and standardized tests will always overshadow the value they place on participating in studies to evaluate the effectiveness of prevention curricula.