Implementing Dementia Caregiver Programs in Real-World Settings: Fidelity Considerations

Testing interventions in real-world settings requires fidelity monitoring to ensure implementation integrity. However, strategies to enhance, monitor, and measure fidelity deployed in efficacy trials may not be feasible in pragmatic trials or sustainable in practice. This paper reviews published translational or pragmatic studies of dementia caregiver support interventions to understand how fidelity was previously treated in order to derive recommendations for future pragmatic-like trials. A search using SCOPUS, EMBASE, and Google Scholar identified 31 translational caregiver intervention studies of which 20 (64.5%) referenced fidelity. Of these 20, 11 (55.0%) reported fidelity measurement, whereas 9 (45.0%) only recognized its importance. Of the 11 studies, fidelity was assessed using investigator-developed scoring forms, audio/video recordings, evaluations from caregivers and interventionists, and by comparing outcomes with the original efficacy trial. Additionally, 7 (63.6%) of 11 studies reported fidelity results, representing only 22.5% of 31 studies reporting outcomes demonstrating the inconsistency in the field concerning the reporting outcomes of fidelity. We conclude that fidelity methods used in translational studies to date are not practical nor sustainable for ongoing monitoring of evidence-based programs in real-world settings and that only 2 aspects of fidelity, intervention and adherence, are considered. New approaches are needed to ensure fidelity integrity in pragmatic trials and which can be sustained thereafter.

Experiences With and Access to Evidence-Based Health Promotion Programs for Older American Indian, Alaska Native, and Native Hawaiian Peoples

Evidence-based programs (EBPs) work effectively for participants whose characteristics match those of the EBP research participants. However, EBPs have been almost exclusively developed and evaluated for the general U.S. population with limited American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) community engagement. Thus, an AI/AN/NH Evidence-Based Program Advisory Council sought to identify AI/AN/NH peoples' experiences with and access to EBPs. We held 20 listening sessions with AI/AN/NH Elder services program staff (n = 118) and with AI/AN/NH Elders (n = 82) and conducted a self-administered online survey with Title VI Directors (n = 63). The six themes that emerged from the listening sessions with staff included misunderstanding community engagement, valuing fidelity over flexibility, lack of cultural awareness, assumptions about available infrastructure, unrealistic implementation timelines, and funding restrictions. Listening session themes with Elders included definitions of aging well, participation motivators, preferred activities, participation barriers, and unmet needs. Survey data indicated that programming of greatest interest for Elders as identified by Title VI Directors and staff included and/or addressed cultural activities (81%), socialization (75%), diabetes (73%), caregiving (68%), and nutrition (68%). Seventy-six percent of survey respondents had heard of EBPs and 24% indicated that EBPs were not being implemented in their community. The Advisory Council developed specific action steps with the goal of improving AI/AN/NH communities' access to culturally appropriate and feasible EBPs. The steps require collective action from federal agencies, national partners, EBP program developers and administrators, local organizations, and Elders to ensure EBPs are accessible and culturally appropriate for AI/AN/NH Elders.

Knowledge and Use of Evidence-Based Programs for Older Adults in the Community: A Survey of Physical Therapy Professionals

BACKGROUND AND PURPOSE

The Agency for Healthcare Research and Quality highlights the need for sustainable linkages between clinical and community settings to enhance prevention and improve care of people with chronic conditions. The first step in promoting linkages is understanding the knowledge and use of evidence-based programs by physical therapy (PT) professionals. Therefore, the objective of this study was to describe the knowledge of and referral to evidence-based programs in the community by a convenience sample of PT professionals and to examine the characteristics of those who refer to evidence-based programs.

METHODS

A cross-sectional web-based survey containing 36 questions regarding respondents' demographics and evidence-based program knowledge and referral practices was disseminated to a convenience sample of PT professionals via email, news-blasts, social media, and word of mouth.

RESULTS AND DISCUSSION

A total of 459 PT professionals completed the survey. Approximately half reported practicing for more than 20 years and 75% are members of the American Physical Therapy Association (APTA). The majority (74%) are aware of evidence-based programs; however, fewer (56%) refer to these programs. Compared with individuals who do not refer to evidence-based programs, individuals who refer are more likely to be involved in PT organizations and be an APTA Geriatrics member. Of the individuals who do not refer to evidence-based programs, 21.5% reported not knowing they existed and 33% reported not knowing where the programs are located.

CONCLUSIONS

Most survey respondents reported knowing about evidence-based programs and more than half reported being aware of the evidence-based programs available in their communities. These results indicate many PT professionals already have a knowledge of evidence-based programs to support clinic-community linkages. As survey respondents were a sample of convenience and likely do not represent all PT professionals in the United States, the results should be interpreted with caution. Additional research on a more representative sample is needed to fully understand the current utilization of evidence-based programs, which will enable us to design efforts to improve the clinic to community transition. Improving linkages between PT professionals and community resources has the potential to benefit both patients and clinicians and lessen the burden on the health care system.

State Department and Provider Agency Utilization of Evidence-Based Program Registries in Behavioral Healthcare and Child Welfare

Evidence-based program registries (EBPRs) are web-based compilations of behavioral healthcare programs/interventions that rely on research-based criteria to rate program efficacy or effectiveness for support of programmatic decision-making. The objective was to determine the extent to which behavioral health decision-makers access EBPRs and to understand whether and exactly how they use the information obtained from EPBRs. Single State Authorities (SSAs) and service provider agencies in the areas of behavioral health and child welfare were recruited nationally. Senior staff (n = 375) responsible for the selection and implementation of programs and/or policies were interviewed by telephone concerning their visits (if any) to 28 relevant EBPRs, the types of information they were seeking, whether they found it, and how they may have used that information to effect changes in their organizations. At least one EBPR was visited by 80% of the respondents, with a median of three different registers being visited. Most visitors (55%) found all the information they were seeking; those who did not desired more guidance or tools for individual program implementation or were unable to locate the program or practice that they were seeking. Most visitors (65%) related using the information obtained to make changes in their organizations, in particular to select, start or change a program, or to support the adoption or improvement of evidence-based clinical practices. EBPRs were shown to be important resources for dissemination of research-based program effectiveness data, leading to increased use of evidence-based practices in the field, but the study also identified needs for greater awareness of EBPRs generally and for more attention to implementation of specific recommended programs and practices.

Enhancing the Adoption of Evidence-Based Health Marketing and Promotion Strategies in Local Communities: Building a Communication Dissemination and Support System for the National Diabetes Prevention Program

The Centers for Disease Control and Prevention (CDC) created a health communication marketing and promotion support system (support system) to help 10 CDC-funded national organizations (recipients) grow enrollment of underserved populations in the National Diabetes Prevention Program. This article describes the creation of a successful support system to increase the use of effective marketing approaches and key messaging. The support system was developed using a systematic approach. It included a needs assessment, audience research, marketing strategy identification, expert panel review, materials development, and dissemination guidance. Hands-on, individualized, and group end-user training and technical assistance was also included. Recipients received culturally and linguistically tailored marketing materials to support their specific priority audiences, as well as corresponding training on recommended dissemination methods. In in-depth key-informant interviews, staff from six recipients reported increased knowledge of local communities and audiences, efficacy and skills to conduct media interviews, capacity to identify and train champions and influencers, and greater community partner investments. With marketing support, 90% of recipients reported increased enrollment, of which 40% exceeded self-set targets and another 40% doubled or tripled their enrollment numbers. These findings indicate that a customized strategic health communication marketing and promotion support system presents a significant opportunity to help recipients increase enrollment in evidence-based interventions. Practitioners disseminating evidence-based interventions may consider a support system to increase program uptake.

The Development, Evaluation, and Implementation of Parenting-focused Prevention Programs in Collaboration with Family Court

Promoting the well-being and best interests of children in separated and divorcing families is a shared value among family court professionals and prevention scientists who develop and evaluate intervention programs. This article chronicles the development, evaluation, and implementation of two programs - the New Beginnings Program (NBP), a parenting intervention for separated/divorcing parents and the Family Transitions Guide (FTG), an intervention designed to motivate high conflict separated/divorcing parents to attend the NBP. The development and evaluation of these programs was facilitated by a long-standing collaboration with Maricopa Family Court. We discuss the process of developing these programs, their underlying small theories, and the evaluation of their effects in randomized trials. We also describe our collaboration with the family court and ways that the court promoted the development and evaluation of these programs. Finally, we summarize lessons learned and discuss future directions to bolster the public health impact of evidence-based programs for separated/divorcing families.

One Year Follow Up Efficacy of the Coping Power Universal and Its Relations with Teachers' Occupational Stress

The coping power universal (CPU) is an evidence-based universal prevention program delivered by teachers, and completely integrated into the school agenda. Previous studies have shown its positive effects, though little is known about its longer-term effects, and no previous study has explored whether teachers’ occupational stress could influence the CPU efficacy. The current study aimed to explore the 1 year follow up of the CPU on students’ externalizing and internalizing problems and prosocial behavior, and the influence of baseline levels of teachers’ stress in a sample of 316 3rd graders and their teachers (N = 32). Results showed that the CPU led to positive effects, not attainable with the standard curriculum. Additionally, improvements in prosocial behavior persisted even one year after the conclusion of the program. However, improvements in internalizing and externalizing problems were not maintained at the follow up, highlighting the need to understand the factors influencing the CPU efficacy. In this regard, our findings showed that high levels of teachers’ occupational stress predicted poorer improvements following the CPU, and an increase in students’ difficulties at the follow-up assessment. Addressing teachers’ stress as part of prevention programs for students could boost their efficacy and yield more lasting results.

Clinical-Community Connections: Incorporating Evidence-Based Programs for Improved Patient Outcomes

Incorporating evidence-based community programs into clinical care recommendations and goals may help bridge the clinic-to-community transition for older adults. Engagement in evidence-based programs can help older adults manage chronic conditions and reduce fall risk through behavior change and self-management following a clinical episode of care. This paper describes evidence-based fall prevention and physical activity programs, provides resources to locate programs, and strategies to match older adults to the right programs.

Improving Evidence-Based Program Repositories: Introducing the Evidence-Based Cancer Control Programs (EBCCP) Web Repository

To reduce the research to practice gap, promoting the utility of evidence-based repositories is essential among both practitioners and researchers. Organizing these repositories to address the needs of these audiences requires a user-centered design approach as proposed recently in an article by Harden et al, 2020. This commentary builds on the proposed solutions to introduce a recently redesigned Evidence-Based Cancer Control Programs (EBCCP) web repository (formerly Research-Tested Intervention Programs (RTIPs)) from the National Cancer Institute. Specifically, we describe the user-centered redesign process, strategies for broader dissemination of the repository using digital tools and provide future directions for the evidence-based program repository.

Community Stakeholders' Perspectives on Introducing Human Papillomavirus Vaccination and Biobanking Evidence-Based Programs Within Medically Underserved Communities: A Community-Engaged Approach

PURPOSE

We explored the perspectives of program coordinators and community leaders from Community-based-organizations (CBOs) and Faith-based-organizations (FBOs) to determine how information on human papillomavirus (HPV) vaccination and biobanking is understood and supported within medically underserved communities, and identified strategies for introducing evidence-based programs (EBP) on HPV vaccination and biobanking within underserved communities.

METHODS

The EPIS framework guided discussions in four focus groups with program coordinators (n = 27) and one-on-one interviews with community leaders (n = 15) from CBOs and FBOs.

RESULTS

Participants reported that community members were aware of HPV vaccination but did not know of the link between HPV infection and cancers. Awareness for biobanking was low. HPV vaccination and biobanking were not priority health concerns among community members due to other health issues. However, HPV vaccination and biobanking were considered sensitive health topics. For HPV vaccination, sensitivity was due to concerns that HPV vaccination promoted sex among adolescents, while for biobanking, sensitivity was due to historical abuses of people of color by the medical community. Participants reported that program coordinators' awareness of HPV vaccination and biobanking depended on their organizations' mission. Neither were considered a priority health concern due to lack of funding. Few EBP were available on HPV vaccination and biobanking. Recommendations on culturally-appropriate strategies for engaging community members on HPV vaccination and biobanking EBP are discussed.

CONCLUSION

Given the promise of HPV vaccination and the Precision Medicine Initiative to reduce cancer disparities, findings elucidate factors to be considered when implementing EBP on HPV vaccination and biobanking into medically underserved communities.

Sustained effects of a school readiness intervention: 5th grade outcomes of the Head Start REDI program

This study examined the sustained effects of the Head Start Research-based Developmentally Informed (REDI) program, which enriched preschools with evidence-based programming targeting social-emotional and language/emergent literacy skills. 44 Head Start classrooms were randomly assigned to intervention or a usual practice control group, and 356 4-year-olds (25% African American, 17% Latino, 54% female) were followed through the end of 5th grade. Growth curve analyses revealed that significant intervention effects on teacher-rated social adjustment, academic engagement, and parent involvement identified at the end of the Head Start year were sustained throughout elementary school. These findings demonstrate that evidence-based curricula combined with professional development support can enhance preschool programming and promote the elementary school adjustment of children living in poverty.

Community capacity coach: Embedded support to implement evidenced-based prevention

Given the pervasive nature of child abuse and neglect, multilevel public health approaches are necessary. Implementation science can help in understanding the most effective ways to build infrastructure and support delivery of such approaches. In this theoretical paper, we describe the implementation of the Positive Parenting Program (Triple P), an evidence-based population-level parenting program in South Carolina. While implementation science has informed how to move population-level efforts to scale, we discuss challenges that persist in practice, such as when there is a need for multiple stakeholders to understand, support, and apply implementation best practices in a systematic and consistent way. To address this challenge, we introduce the role of a Community Capacity Coach, who lives in the local community and works towards the implementation of Triple P. The Coach is responsible for bridging gaps between the local community and statewide support systems. We detail the ways in which the Coach's role aligns with key intermediary functions, and how the Coach is embedded within the larger Triple P statewide support system. We then discuss the assessment of the Coach's impact; and conclude with future directions and next steps for this role within Triple P South Carolina.

Outcomes associated with scale-up of the Stepping On falls prevention program: A case study in redesigning for dissemination

Introduction:

Translating complex behavior change interventions into practice can be accompanied by a loss of fidelity and effectiveness. We present the evaluation of two sequential phases of implementation of a complex evidence-based community workshop to reduce falls, using the Replicating Effective Programs Framework. Between the two phases, workshop training and delivery were revised to improve fidelity with key elements.

Methods:

Stepping On program participants completed a questionnaire at baseline (phase 1: n = 361; phase 2: n = 2219) and 6 months post-workshop (phase 1: n = 232; phase 2: n = 1281). Phase 2 participants had an additional follow-up at 12 months (n = 883). Outcomes were the number of falls in the prior 6 months and the Falls Behavioral Scale (FaB) score.

Results:

Workshop participation in phase 1 was associated with a 6% reduction in falls (RR = 0.94, 95% CI 0.74–1.20) and a 0.14 improvement in FaB score (95% CI, 0.11– 0.18) at 6 months. Workshop participation in phase 2 was associated with a 38% reduction in falls (RR = 0.62, 95% CI 0.57–0.68) and a 0.16 improvement in FaB score (95% CI 0.14–0.18) at 6 months, and a 28% reduction in falls (RR = 0.72, 95% CI 0.65–0.80) and a 0.19 score improvement in FaB score (95% CI 0.17–0.21) at 12-month follow-up.

Conclusions:

Effectiveness can be maintained with widespread dissemination of a complex behavior change intervention if attention is paid to fidelity of key elements. An essential role for implementation science is to ensure effectiveness as programs transition from research to practice.

Making Evidence-Based Interventions Relevant for Users: A Comparison of Requirements for Dissemination Readiness Across Program Registries

This study compares prevention program registries in current use on their level of support for users seeking to implement evidence-based programs. Despite the importance of registries as intermediaries between researchers and the public, and although previous studies have examined how registries define their standards for methodological soundness and evidence of efficacy, little research has focused on the degree to which registries consider programs' dissemination readiness. The result is that registry users are uncertain whether listed programs and their necessary support materials are even available for implementation. This study evaluates 11 publicly and privately funded prevention registries that review the evidence base of programs seeking to improve child health and prosocial outcomes on the degree to which they use dissemination readiness as an evidentiary criterion for rating programs, and the extent and type of information they provide about dissemination readiness to support real-world implementation. The results show wide variability, with few having standards about dissemination readiness or making evidence-based information about interventions easily accessible to users. Findings indicate the need for registries to (1) do more to assess dissemination readiness before including programs on their website and (2) offer more complete information on dissemination readiness and implementation support to users.

Designing Capacity-Building Supports to Promote Evidence-Based Programs in Community-Based Organizations Working with Underserved Populations

BACKGROUND

It is critical to build capacity to use evidence-based health promotion programs in community-based organizations (CBOs), particularly those working with underserved populations. Packages of ongoing capacity-building supports seem to be critical, but it is not clear how best to design and deploy them.

OBJECTIVES

PLANET MassCONECT was a participatory research project to increase capacity for the use of evidence-based programs (EBPs) among CBO staff members in three Massachusetts communities experiencing health disparities. We assessed the impact of trainee engagement with capacity-building supports on the use of a systematic approach to program planning.

METHODS

Trainees were enrolled from 2010 to 2012 and engaged until 2014. The intervention started with a workshop and included ongoing capacity-building supports (a customized web portal and resources, networking events, minigrants, and technical assistance). Logistic regression was used to examine the relationship between trainee engagement with capacity-building supports offered after the workshop and key outcomes at year 1.

RESULTS

Of the capacity-building supports offered after the workshop, the web portal was the most popular. Higher use of systematic program planning approaches in the first year was predicted by web portal use (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.04-8.67; p = 0.04), and participation in the minigrant process (OR, 5.40; 95% CI, 1.09-28.69; p = 0.04). Separately, high intention to use systematic approaches for program planning was predicted by web portal use (OR, 3.47; 95% CI, 1.27-9.52; p = 0.02).

CONCLUSIONS

Ongoing capacity-building supports may promote EBP planning in CBOs, but institutional constraints may limit practitioners' ability to engage with such supports.

Engaging the Underrepresented Sex: Male Participation in Chronic Disease Self-Management Education (CDSME) Programs

Females are more likely than males to participate in evidence-based health promotion and disease prevention programs targeted for middle-aged and older adults. Despite the availability and benefits of Stanford's Chronic Disease Self-Management Education (CDSME) programs, male participation remains low. This study identifies personal characteristics of males who attended CDSME program workshops and identifies factors associated with successful intervention completion. Data were analyzed from 45,375 male CDSME program participants nationwide. Logistic regression was performed to examine factors associated with workshop attendance. Males who were aged 65-79 (OR = 1.27, p < .001), Hispanic (OR = 1.22, p < .001), African American (OR = 1.13, p < .001), Asian/Pacific Islander (OR = 1.26, p < .001), Native Hawaiian (OR = 3.14, p < .001), and residing in nonmetro areas (OR = 1.26, p < .001) were more likely to complete the intervention. Participants with 3+ chronic conditions were less likely to complete the intervention (OR = 0.87, p < .001). Compared to health-care organization participants, participants who attended workshops at senior centers (OR = 1.38, p < .001), community/multipurpose facilities (OR = 1.21, p < .001), and faith-based organizations (OR = 1.37, p < .001) were more likely to complete the intervention. Men who participated in workshops with more men were more likely to complete the intervention (OR = 2.14, p < .001). Once enrolled, a large proportion of males obtained an adequate intervention dose. Findings highlight potential strategies to retain men in CDSME programs, which include diversifying workshop locations, incorporating Session Zero before CDSME workshops, and using alternative delivery modalities (e.g., online).

Braiding Two Evidence-based Programs for Families at-risk: Results of a Cluster Randomized Trial

Child maltreatment is a significant public health problem best addressed through evidence-based parent-support programs. There is a wide range of programs with different strengths offering a variety of options for families. Choosing one single evidence-based program often limits the range of services available to meet the unique needs of families. This paper presents findings from a study to examine the systematic braiding of two evidence-based programs, Parents as Teachers and SafeCare at Home (PATSCH), with the goal to provide a more robust intervention for higher risk families. A cluster randomized effectiveness trial was conducted to examine if PATSCH improved parenting behaviors known to decrease the risk for child maltreatment compared to Parents as Teachers (PAT) Alone. Parents (N= 159; 92 PAT Alone; 67 PATSCH) were enrolled to complete a baseline, 6-month and 12-month assessment. Results indicate the groups did not differ on number of environmental hazards in the home, parents' health care decision-making abilities, child abuse potential, and physical assault over time. However, with regard to the potential for child abuse, the PATSCH group showed a decrease in nonviolence discipline and increase in psychological aggression compared to the PAT group. Further research is needed to better examine this concept and its implications for the field.

Effectiveness of a Lifestyle Intervention on Social Support, Self-Efficacy, and Physical Activity among Older Adults: Evaluation of Texercise Select

Despite the well-recognized benefits of physical activity across the life course, older adults are more inactive than other age groups. The current study examines the effects of Texercise Select participation on self-reported sedentary, light, moderate, and vigorous physical activity. Secondarily, this study examined intervention effects on two potential facilitators of physical activity: (1) self-efficacy for being more physically active and (2) social support received for physical activity. This study used a non-equivalent group design with self-reported surveys administered at baseline, three-month (immediate post for cases) and six-month follow-ups for the intervention (n = 163) and a comparison group (n = 267). Multivariable mixed model analyses were conducted controlling for age, sex, race, ethnicity, education, comorbid conditions, and site. Among the intervention group, the program had significant immediate effects on most primary outcomes (p < 0.05) at three months. Furthermore, significant improvements were observed for all physical activity intensity levels at six months (p < 0.05). The reduction in sedentary behavior and increases in all physical activity intensity levels were significantly greater from baseline to three-month and baseline to six-month follow-ups among intervention group participants relative to those in the comparison group. This study confirms the effectiveness of Texercise Select to reduce sedentary behavior and improve physicality, supporting the intervention’s robustness as a scalable and sustainable evidence-based program. It also counters negative stereotypes that older adults are not interested in attending multi-modal lifestyle intervention programs nor able to make health behavior changes that can improve health and overall functioning.

Implementing a Braided Home-based Parent-support Curriculum: Lessons Learned

A singular parent-support program is limited in its ability to address multiple child and family needs. One innovative solution is braiding, a process in which two evidence-based programs are systematically combined as a newly tailored, cohesive curriculum. In this paper we describe the systematic braiding of two parent-support curricula, Parents as Teachers® and SafeCare®. We highlight implementation challenges to inform future planning and braiding efforts. Based on qualitative data (n = 13), we discuss five lessons learned, including identifying a pedagogical approach and sustainability at the model- and site-level. Implications and future directions for braiding and implementation are also discussed.

Exploration of Factors Predictive of At-risk Fathers' Participation in a Pilot Study of an Augmented Evidence-Based Parent Training Program: A Mixed Methods Approach

There has been burgeoning parenting intervention research specifically addressing fathers in recent decades. Corresponding research examining their participation and engagement in evidence-based parent training programs, which have almost exclusively targeted mothers, is just emerging. The current study used mixed methods to examine factors that influenced completion of an augmented version of an evidence-based child maltreatment prevention program developed for male caregivers called SafeCare Dad to Kids (Dad2K) in a pilot study. The current sample comprised 50 male caregivers (Mage = 29.42 years, SD = 8.18) of a child between the ages of 2 and 5 years. Fathers participated in a baseline assessment and were considered program completers (n = 27) if they participated in the program's six home visiting sessions. A subsample of completers (n = 11) was recruited to participate in qualitative interviews that provided in-depth information about fathers' experiences in Dad2K. Logistic regression indicated that, in the context of other demographic predictors, fathers with an education beyond high school were over 5 times more likely to complete Dad2K program compared to fathers with a high school education or less. Qualitative analyses revealed that interviewed father completers were motivated to enroll and participate in a fathering program because of an interest to learn and obtain skills to make them a better parent. Fathers with a high school education or less may require additional engagement strategies to help proactively encourage their enrollment and completion of parent training programs.

Reported Systems Changes and Sustainability Perceptions of Three State Departments of Health Implementing Multi-Faceted Evidence-Based Fall Prevention Efforts

Although the concepts of systems change and sustainability are not new, little is known about the factors associated with systems change sustaining multi-state, multi-level fall prevention efforts. This exploratory study focuses on three State Departments of Health (DOH) that were awarded 5-year funding from the Centers for Disease Control and Prevention to simultaneously implement four separate yet related evidence-based fall prevention initiatives at the clinical, community, and policy level. The purpose of this study was to examine changes in partnerships and collaborative activities that occurred to accomplish project goals (examining changes in the context of “before funding” and “after funding was received”). Additionally, this study explored changes in State DOH perceptions about action related to sustainability indicators in the context of “during funding” and “after funding ends.” Findings from this study document the partnership and activity changes necessary to achieve defined fall prevention goals after funding is received, and that the importance of sustainability indicator documentation is seen as relevant during funding, but less so after the funding ends. Findings from this study have practice and research implications that can inform future funded efforts in terms of sector and stakeholder engagement necessary for initiating, implementing, and sustaining community- and clinical-based fall prevention interventions.

Advancing Community-Based Falls Prevention Programs for Older Adults-The Work of the Administration for Community Living/Administration on Aging

The mission of the Administration for Community Living (ACL) is to maximize the independence, well-being, and health of older adults, people with disabilities across the lifespan, and their families and caregivers. In direct alignment with this mission is ACL’s support of evidence-based falls prevention programs in communities throughout the United States. Since 2014, the Administration on Aging (AoA), part of ACL, has invested nearly $14 million in entities such as state agencies, nonprofits, and universities to expand access to proven community-based falls prevention programs. The initiatives supported by ACL/AoA bring to bear two primary goals—(1) to significantly increase the number of older adults and older adults with disabilities at risk for falls who participate in evidence-based community programs to reduce falls and falls risks; and (2) to implement innovative funding arrangements, including contracts, partnerships, and collaborations with one or more sustainability partners to support these programs during and beyond the grant period. Support from ACL/AoA has significantly increased the availability of evidence-based falls prevention programs in funded communities, as well as enhanced the network’s sustainable delivery infrastructure to promote continued access to these critical programs beyond the scope of grant funding. This article highlights the successful rollout of ACL/AoA’s falls prevention initiative.

Scaling Up a Multifaceted Violence Prevention Package: County-Level Impact of the North Carolina Youth Violence Prevention Center

OBJECTIVE

Multifaceted approaches to youth-violence prevention package evidence-based programs into initiatives that yield large-scale impact. This study assessed the impact of a package of evidence-based violence prevention programs, implemented as part of the North Carolina Youth Violence Prevention Center, on county-level violence indicators.

METHOD

Using growth-curve modeling, the target county was compared to all other counties in North Carolina and a comparison county.

RESULTS

Results reveal downward trends on several county-level indicators (i.e., undisciplined/delinquent complaints, total delinquent complaints, juvenile arrests-aggravated assaults, and short-term suspensions) throughout the intervention period. However, statistical tests were unable to confirm that intervention-period scores on youth-violence indicators were significantly different than expected scores given the relationship between pretest and intervention-period scores in other North Carolina counties.

CONCLUSIONS

Although additional administrative data points are needed to support the hypotheses, this study provides preliminary evidence of the effectiveness of North Carolina Youth Violence Prevention Center interventions.

Audit Culture: Unintended Consequences of Accountability Practices in Evidence-Based Programs

Evaluation has become expected within the nonprofit sector, including HIV prevention service delivery through community-based organizations (CBOs). While staff and directors at CBOs may acknowledge the potential contribution of evaluation data to the improvement of agency services, the results of evaluation are often used to demonstrate fiscal prudence, efficiency, and accountability to funders and the public, rather than to produce information for the organization's benefit. We conducted 22 in-depth, semistructured interviews with service providers from four agencies implementing the same evidence-based HIV prevention intervention. We use the lens of "audit culture" to understand how the evaluation and accountability mandates of evidence-based program implementation within HIV prevention service provision affect provider-client relations, staff members' daily work, and organizational focus in natural settings, or contexts without continuous support and implementation monitoring. We conclude with recommendations for improving the use and methods of evaluation within HIV prevention service delivery.

Mixed picture of readiness for adoption of evidence-based prevention programs in communities: exploratory surveys of state program delivery systems

An emerging literature highlights the potential for broader dissemination of evidence-based prevention programs in communities through existing state systems, such as the land grant university Extension outreach system and departments of public education and health (DOE-DPH). This exploratory study entailed surveying representatives of the national Extension system and DOE-DPH, to evaluate dissemination readiness factors, as part of a larger project on an evidence-based program delivery model called PROSPER. In addition to assessing systems' readiness factors, differences among US regions and comparative levels of readiness between state systems were evaluated. The Extension web-based survey sample N was 958 and the DOE-DPH telephone survey N was 338, with response rates of 23 and 79 %, respectively. Extension survey results suggested only a moderate level of overall readiness nationally, with relatively higher perceived need for collaborative efforts and relatively lower perceived resource availability. There were significant regional differences on all factors, generally favoring the Northeast. Results from DOE-DPH surveys showed significantly higher levels for all readiness factors, compared with Extension systems. Overall, the findings present a mixed picture. Although there were clear challenges related to measuring readiness in complex systems, addressing currently limited dissemination resources, and devising strategies for optimizing readiness, all systems showed some readiness-related strengths.

National dissemination of multiple evidence-based disease prevention programs: reach to vulnerable older adults

Older adults, who are racial/ethnic minorities, report multiple chronic conditions, reside in medically underserved rural areas, or have low incomes carry a high burden of chronic illness but traditionally lack access to disease prevention programs. The Chronic Disease Self-Management Program (CDSMP), A Matter of Balance/Volunteer Lay Leader (AMOB/VLL), and EnhanceFitness (EF) are widely disseminated evidence-based programs (EBP), but the extent to which they are simultaneously delivered in communities to reach vulnerable populations has not been documented. We conducted cross-sectional analyses of three EBP disseminated within 27 states throughout the United States (US) (2006-2009) as part of the Administration on Aging (AoA) Evidence-Based Disease and Disability Prevention Initiative, which received co-funding from the Atlantic Philanthropies. This study measures the extent to which CDSMP, AMOB/VLL, and EF reached vulnerable older adults. It also examines characteristics of communities offering one of these programs relative to those simultaneously offering two or all three programs. Minority/ethnic participants represented 38% for CDSMP, 26% for AMOB/VLL, and 43% for EF. Rural participation was 18% for CDSMP, 17% for AMOB/VLL, and 25% for EF. Those with comorbidities included 63.2% for CDSMP, 58.7% for AMOB/VLL, and 63.6% for EF while approximately one-quarter of participants had incomes under $15,000 for all programs. Rural areas and health professional shortage areas (HPSA) tended to deliver fewer EBP relative to urban areas and non-HPSA. These EBP attract diverse older adult participants. Findings highlight the capability of communities to serve potentially vulnerable older adults by offering multiple EBP. Because each program addresses unique issues facing this older population, further research is needed to better understand how communities can introduce, embed, and sustain multiple EBP to ensure widespread access and utilization, especially to traditionally underserved subgroups.

Methods for streamlining intervention fidelity checklists: an example from the chronic disease self-management program

Maintaining intervention fidelity should be part of any programmatic quality assurance (QA) plan and is often a licensure requirement. However, fidelity checklists designed by original program developers are often lengthy, which makes compliance difficult once programs become widely disseminated in the field. As a case example, we used Stanford's original Chronic Disease Self-Management Program (CDSMP) fidelity checklist of 157 items to demonstrate heuristic procedures for generating shorter fidelity checklists. Using an expert consensus approach, we sought feedback from active master trainers registered with the Stanford University Patient Education Research Center about which items were most essential to, and also feasible for, assessing fidelity. We conducted three sequential surveys and one expert group-teleconference call. Three versions of the fidelity checklist were created using different statistical and methodological criteria. In a final group-teleconference call with seven national experts, there was unanimous agreement that all three final versions (e.g., a 34-item version, a 20-item version, and a 12-item version) should be made available because the purpose and resources for administering a checklist might vary from one setting to another. This study highlights the methodology used to generate shorter versions of a fidelity checklist, which has potential to inform future QA efforts for this and other evidence-based programs (EBP) for older adults delivered in community settings. With CDSMP and other EBP, it is important to differentiate between program fidelity as mandated by program developers for licensure, and intervention fidelity tools for providing an "at-a-glance" snapshot of the level of compliance to selected program indicators.

Factors Associated with Successful Completion of the Chronic Disease Self-Management Program among Middle-Aged and Older Asian-American Participants: A National Study

Asian-Americans are a small but fast-growing population in the United States who are increasingly experiencing multiple chronic diseases. While the evidence-based Chronic Disease Self-Management Program (CDSMP) has been disseminated among various racial and ethnic populations, few studies specifically investigate participants with an Asian background. The study aims to identify characteristics of middle-aged and older Asian-American CDSMP participants (older than 50 years) and investigate factors related to successful workshop completion (i.e., attending 4+ of the 6 sessions) among this population. Data were analyzed from 2,716 middle-aged and older Asian-Americans collected during a 2-year national dissemination of CDSMP. Multilevel logistic regression analyses were conducted to identify individual- and workshop-level covariates related to successful workshop completion. The majority of participants were female, living with others, and living in metro areas. The average age was 71.3 years old (±9.2), and the average number of chronic conditions was 2.0 (±1.5). Successful completion of CDSMP workshops among participants was associated with their number of chronic conditions (OR = 1.10, P = 0.011), living in non-metro areas (OR = 1.77, P = 0.009), attending workshops from area agencies on aging (OR = 1.56, P = 0.018), and attending a workshop with higher completion rates (OR = 1.03, P < 0.001). This study is the first large-scale examination of Asian-American participants enrolled in CDSMP and highlights characteristics related to intervention attendance among this under-studied minority population. Knowing such characteristics is important for serving the growing number of Asian-Americans with chronic conditions.

The role of session zero in successful completion of chronic disease self-management program workshops

BACKGROUND

The Chronic Disease Self-Management Program (CDSMP) has been widely disseminated among various racial and ethnic populations. In addition to the six required CDSMP workshop sessions, the delivery sites have the option to offer a Session Zero (or zero class), an information session offered prior to Session One as a marketing tool. Despite assumptions that a zero class is helpful, little is known about the prevalence of these additional sessions or their impact on retaining participants in CDSMP workshops. This study aims to describe the proportion of CDSMP workshops that offered Session Zero and examine the association between Session Zero and workshop completion rates.

METHODS

Data were analyzed from 80,987 middle-aged and older adults collected during a two-year national dissemination of CDSMP. Generalized estimating equation regression analyses were conducted to assess the association between Session Zero and successful workshop completion (attending four or more of the six workshop sessions).

RESULTS

On average, 21.04% of the participants attended workshops that offered Session Zero, and 75.33% successfully completed the CDSMP workshop. The participants of the workshops that offered Session Zero had significantly higher odds of completing CDSMP workshops than those who were not offered Session Zero (OR = 1.099, P = <0.001) after controlling for participants' demographic characteristics, race, ethnicity, living status, household income, number of chronic conditions, and workshop delivery type.

CONCLUSION

As one of the first studies reporting the importance of an orientation session for participant retention in chronic disease management intervention projects, our findings suggest offering an orientation session may increase participant retention in similar translational efforts.

Adoption of Evidence-Based Health Promotion Programs: Perspectives of Early Adopters of Enhance(®)Fitness in YMCA-Affiliated Sites

Purpose

To identify facilitators and barriers among early adopters of Enhance^®Fitness (EF), in Young Men’s Christian Association-affiliated (Y-affiliated) sites from the perspective of program staff. EF is an evidence-based group exercise program for seniors.

Methods

This qualitative study used semi-structured phone interviews with 15 staff members representing 14 Y-affiliated sites. Interviews were digitally recorded, transcribed, and analyzed using qualitative content analysis informed by the RE-AIM framework.

Findings

Staff were, on average, 48.7 years old (SD 13.5) and had been involved with EF for 5.2 years (SD 3.1). Key themes related to facilitating adoption of EF were: match with the Y mission, support from different organizational levels, match between the target population need and EF, initial and on-going financial support, presence of champions, novelty of EF, an invitation to partner with a community-based organization to offer EF, and program-specific characteristics of EF. Key themes related to barriers interfering with EF adoption included competing organizational programs and space limitations, limited resources and expertise, and costs of offering the program.

Implications

Our findings identify the types of organizational support needed for adoption of evidence-based health promotion programs like EF. Recommendations for practice, research, and policy based on the findings, including assessing organizational readiness, researching late adopters, and developing revenue streams, may help facilitate program adoption. Packaging and sharing these practical recommendations could help community-based agencies and nationally networked organizations facilitate adoption of EF and other evidence-based programs.

Programs to improve adolescent sexual and reproductive health in the US: a review of the evidence

BACKGROUND

US adolescents have high rates of teen pregnancy, childbearing, and sexually transmitted infections (STIs), highlighting the need to identify and implement effective programs that will help improve teen sexual and reproductive health.

MATERIALS AND METHODS

This review identified 103 random-assignment evaluations of 85 programs that incorporated intent-to-treat analyses and assessed impacts on pregnancy, childbearing, STIs, and their key determinants - sexual activity, number of sexual partners, condom use, and other contraceptive use - among teens. This review describes the evidence base for five broad program approaches, including abstinence education, comprehensive sex education, clinic-based programs, youth development programs, and parent-youth relationship programs. We also describe programs with impacts on key outcomes, including pregnancy/childbearing, STIs, and those that found impacts on both sexual activity and contraceptive use.

RESULTS

Our review identified 52 effective programs: 38 with consistent impacts on reproductive health outcomes, and 14 with mixed findings (across subpopulations, follow-ups, or multiple measures of a single outcome). We found that a variety of program approaches produced impacts on sexual and reproductive health outcomes. Parent-youth relationship programs and clinic-based program evaluations more frequently showed impacts than other program approaches, although we also identified a number of abstinence-education, comprehensive sex education, and youth-development programs with impacts on sexual and reproductive health outcomes. Overall, we identified nine program evaluations with impacts on teen pregnancies or births, five with impacts on reducing STIs, and 15 with impacts on both delaying/reducing sexual activity and increasing contraceptive use (including condom use).

CONCLUSION

Future efforts should conduct replications of existing program evaluations, identify implementation components linked to impacts, rigorously evaluate programs that appear promising, and expand the evidence base on programs that impact hormonal and long-acting contraceptive method use.

Comparing rating paradigms for evidence-based program registers in behavioral health: evidentiary criteria and implications for assessing programs

Decision makers need timely and credible information about the effectiveness of behavioral health interventions. Online evidence-based program registers (EBPRs) have been developed to address this need. However, the methods by which these registers determine programs and practices as being “evidence-based” has not been investigated in detail. This paper examines the evidentiary criteria EBPRs use to rate programs and the implications for how different registers rate the same programs. Although the registers tend to employ a standard Campbellian hierarchy of evidence to assess evaluation results, there is also considerable disagreement among the registers about what constitutes an adequate research design and sufficient data for designating a program as evidence-based. Additionally, differences exist in how registers report findings of “no effect,” which may deprive users of important information. Of all programs on the 15 registers that rate individual programs, 79% appear on only one register. Among a random sample of 100 programs rated by more than one register, 42% were inconsistently rated by the multiple registers to some degree.

Preparing the workforce for healthy aging programs: the Skills for Healthy Aging Resources and Programs (SHARP) model

Current public health and aging service agency personnel have little training in gerontology, and virtually no training in evidence-based health promotion and disease management programs for older adults. These programs are rapidly becoming the future of our community-based long-term care support system. The purpose of this project was to develop and test a model community college career technical education program, Skills for Healthy Aging Resources and Programs (SHARP), for undergraduate college students, current personnel in aging service and community organizations, and others interested in retraining. A multidisciplinary cross-sector team from disciplines of public health, sociology, gerontology and nursing developed four competency-based courses that focus on healthy aging, behavior change strategies, program management, an internship, and an option for leader training in the Chronic Disease Self-Management Program. To enhance implementation and fidelity, intensive faculty development training was provided to all instructors and community agency partners. Baseline and postprogram evaluation of competencies for faculty and students was conducted. Process evaluation for both groups focused on satisfaction with the curricula and suggestions for program improvement. SHARP has been piloted five times at two community colleges. Trainees (n = 113) were primarily community college students (n = 108) and current aging service personnel (n = 5). Statistically significant improvements in all competencies were found for both faculty and students. Process evaluation outcomes identified the needed logical and component adaptations to enhance the feasibility of program implementation, dissemination, and student satisfaction. The SHARP program provides a well-tested, evidence-based effective model for addressing workforce preparation in support of healthy aging service program expansion and delivery.

Technology-Based Innovations in Child Maltreatment Prevention Programs: Examples from SafeCare®

Each year, hundreds of thousands of children in the U.S. are victims of child maltreatment. Experts recommend behavioral, skill-based parent training programs as a strategy for the prevention of child abuse and neglect. These programs can be enhanced using innovative technology strategies. This paper presents a brief history of the use of technology in SafeCare®, a home visiting program shown to prevent child neglect and physical abuse, and highlights current work that takes a technology-based hybrid approach to SafeCare delivery. With this unique approach, the provider brings a tablet computer to each session, and the parent interacts with the software to receive psychoeducation and modeling of target skills. The provider and parent then work together to practice the targeted skills until mastery is achieved. Initial findings from ongoing research of both of these strategies indicate that they show potential for improving engagement and use of positive parenting skills for parents and ease of implementation for providers. Future directions for technology enhancements in SafeCare are also presented.

Assessing awareness and use of evidence-based programs for cancer control in Puerto Rico

The Community Cancer Control Outreach Program (CCCOP) is a community-academic partnership aimed at developing and implementing a cancer control outreach, research, and training program in Puerto Rico. The CCCOP surveyed 56 partners to assess their awareness, training needs, and use of resources related to evidence-based programs (EBPs). Despite relatively high levels (70 %) of confidence in adopting EBPs, there were low levels of awareness (37 %) and use (25 %) of existing EBPs resources. Respondents' who had used EBPs resources were more likely to have positive beliefs about EBPs than nonusers (p<0.05). Training needs were high among respondents and no significant differences were found between those who had and had not used existing EBPs resources. These findings can guide the development of training tools and technical assistance to increase the use of EBPs for Latino audiences.

Impact challenges in community science-with-practice: lessons from PROSPER on transformative practitioner-scientist partnerships and prevention infrastructure development

At present, evidence-based programs (EBPs) to reduce youth violence are failing to translate into widespread community practice, despite their potential for impact on this pervasive public health problem. In this paper we address two types of challenges in the achievement of such impact, drawing upon lessons from the implementation of a partnership model called PROSPER. First, we address five key challenges in the achievement of community-level impact through effective community planning and action: readiness and mobilization of community teams; maintaining EBP implementation quality; sustaining community teams and EBPs; demonstrating community-level impact; and continuous, proactive technical assistance. Second, we consider grand challenges in the large-scale translation of EBPs: (1) building, linking and expanding existing infrastructures to support effective EBP delivery systems, and (2) organizing networks of practitioner-scientist partnerships-networks designed to integrate diffusion of EBPs with research that examines effective strategies to do so. The PROSPER partnership model is an evidence-based delivery system for community-based prevention and has evolved through two decades of NIH-funded research, assisted by land grant universities' Cooperative Extension Systems. Findings and lessons of relevance to each of the challenges are summarized. In this context, we outline how practitioner-scientist partnerships can serve to transform EBP delivery systems, particularly in conjunction with supportive federal policy.