Does Narrative Quality Matter During Implementation of a School-Based Prevention Intervention? A Test of Narrative Engagement Theory.

Narratives play a powerful role in sharing meaning and making sense of experiences. Specifically, health narratives convey storylines, characters, and messages about health-related behaviors and provide audiences with models for healthy behaviors, prompting audiences' health-related reflections and decision-making. Narrative engagement theory (NET) explains how personal narratives can be integrated into interventions to promote health. This study utilizes NET to test direct and indirect effects of teachers' narrative quality on adolescent outcomes during a school-based substance use prevention intervention that includes narrative pedagogy and an implementation strategy. Observational coding of teacher narratives in video-recorded lessons along with self-report student surveys (N = 1,683) were subjected to path analysis. Findings showed significant direct effects of narrative quality on student engagement, norms (i.e. personal, best-friend injunctive, and descriptive norms), and substance use behavior. The analysis also yielded support for indirect effects of narrative quality on adolescent substance use behavior via student engagement, personal norms, and descriptive norms. Findings highlight important issues related to teacher-student interaction during implementation and contributes implications for adolescent substance use prevention research.

Testing Narrative Persuasion of a Culturally Grounded, School-Based "Dale Se REAL" Entertainment-Education Intervention and Peer Communication on Nicaraguan Adolescent Substance Use.

Guided by narrative engagement theory and social cognitive theory, the present study investigates effects of narrative persuasion and peer communication on Nicaraguan adolescent substance use. Eighth-grade students in Nicaragua were recruited to participate in the culturally grounded, school-based prevention intervention Dale se REAL and to watch five entertainment-education intervention videos that teach drug refusal communication strategies. Using the cross-sectional survey (N = 224), a path analysis was run to examine the mediated moderation effects of narrative engagement (e.g., interest, realism, and identification with main characters) and peer communication about the intervention videos (e.g., frequency and valence of communication) on adolescent refusal self-efficacy and substance use behaviors. Results revealed that realism was significantly related to adolescent refusal self-efficacy and frequent peer communication moderated the association between refusal self-efficacy and the past 30-day marijuana use. Findings suggest that health communication scholars should take into consideration social factors and cultural contexts for adolescent substance use prevention research.

How Does Family Communication Relate to Adolescent Dating Violence and Externalizing Behaviors? The Role of Parent-Adolescent Risk Communication and Attitudes toward Violence in a Nicaraguan Sample.

Family plays a critical role for adolescent socialization. Parents in particular can promote either adolescent prosocial or problem behaviors. The purpose of the present study is two-fold. The first is to investigate the main and interaction effects of family communication (i.e., verbal hostility and expressiveness) on adolescent risk behaviors (i.e., dating violence and externalizing behaviors). The second is to test whether family communication is indirectly associated with adolescent risk behaviors through parent-adolescent risk communication and adolescent attitudes toward violence. Nicaraguan 7th and 8th graders were recruited to participate in paper-pencil surveys (N = 1,651). Path analysis identified significant main effects of verbal hostility for adolescent dating violence and externalizing behaviors. Although expressiveness did not show a significant main effect, interaction effects with verbal hostility were identified for both dating violence and externalizing behaviors. When verbal hostility was low, expressiveness was negatively related to adolescent dating violence and externalizing behaviors whereas when verbal hostility was high, expressiveness was positively associated with these behaviors. Significant indirect effects were detected only via adolescent attitudes toward violence. Prevention efforts that promote positive family environments and especially that eliminate verbal hostility are suggested.

Is Parent-Adolescent Drug Talk Always Protective? Testing A New Scale of Drug Talk Styles in Relation to Adolescent Personal Norms, Parental Injunctive Norms, Substance Use Intentions, and Behaviors.

According to parent-offspring drug talk (PODT) model, the specificity of drug talk styles is identified by the timing and directness of communication about substance use between parent and adolescent (e.g., situated direct, ongoing direct, situated indirect, and ongoing indirect talk style). Given the limitation of the original, single item measure for drug talk styles with a categorical response option, the current study proposed a new scale of drug talk styles and tested its concurrent validity. Using cross-sectional survey data (N = 2,035), confirmatory factor analysis was conducted to test the factor structure of the scale. Consistent with PODT model, the analysis yielded support for a four-factor structure for the drug talk styles. Next, a path analysis was employed to validate the scale. The findings suggested that situated direct talk was positively related to personal anti-substance-use norms and parental anti-substance-use injunctive norms but negatively related to smoking intention, as well as alcohol use in the past 30 days. Ongoing direct talk, however, was found to be positively associated with alcohol and marijuana use in the past 30 days. Research implications and future directions are discussed.

Positive School Climate as a Moderator of Violence Exposure for Colombian Adolescents.

In Colombia, many adolescents have experienced violence related to the decades-long armed conflict in the country and have witnessed or been directly victimized by violence in their communities, often related to gang activity or drug trafficking. Exposure to violence, both political and community violence, has detrimental implications for adolescent development. This study used data from 1857 Colombian adolescents in an urban setting. We aim to understand the relations between exposure to violence and adolescent outcomes, both externalizing behaviors and developmental competence, and then to understand whether school climate (i.e., safety, connectedness, services) moderates these relations. Results demonstrate that armed conflict, community violence victimization, and witnessing community violence are positively associated with externalizing behaviors, but only armed conflict is negatively associated with developmental competence. School safety, connectedness, and services moderate the relation between community violence witnessing and externalizing behaviors. School services moderates the relation between community violence victimization and developmental competence. As students perceived more positive school climate, the effects of community violence exposure on outcomes were weakened. This study identifies potential levers for intervention regarding how schools can better support violence-affected youth through enhancements to school safety, connectedness, and services.

Trends of Parent-Adolescent Drug Talk Styles in Early Adolescence.

The present study seeks to understand how parents as prevention agents approach substance use prevention messages during the period of early adolescence. Students (N = 410) in a drug prevention trial completed surveys from 7th to 9th grade. Using longitudinal data, a series of latent transition analyses was conducted to identify major trends of parent-adolescent drug talk styles (i.e., never talked, situated direct, ongoing direct, situated indirect, and ongoing indirect) in control and treatment conditions. Findings demonstrate a developmental trend in drug talk styles toward a situated style of talk as youth transitioned from 7th grade to 9th grade. Findings also show that even though the drug prevention trial did not specifically target parental communication, parents in the treatment condition provide more ongoing substance use prevention messages to their adolescent children than do parents in the control condition. The present study discusses relevant developmental issues, potential intervention effects, and future research directions for communication research in substance use prevention.

Implementation Quality: Implications for Intervention and Translational Science.

PURPOSE: Implementation quality (IQ), a critical concept for translational science, measures the discrepancy between an intervention's intended design and its implementation. Quantifying the impact of IQ on intervention outcomes informs efforts to improve intervention translatability. The purpose of this article is to define and describe IQ and its dimensions (content adherence, quality of delivery, and engagement) with a focus on individualized interventions being delivered in research and practice settings. APPROACH: We apply IQ concepts from intervention science in two contexts: (a) an intervention currently being investigated in an efficacy trial, and (b) a practice situation involving the application of evidence-based practice guidelines during clinic visits. IQ measurement approaches are presented using a study protocol, progress notes, interdisciplinary meeting notes, or clinical guidelines, depending upon whether the intervention is delivered during a research study or a clinical encounter. CONCLUSIONS: The investigators describe the necessary infrastructure and support for capturing IQ data and the subsequent complexities and challenges of collecting, measuring, and analyzing these data. Understanding IQ is critical to advancing translational science. Such understanding informs application of appropriate IQ measures, and promotes effective translation of evidence-based interventions into practice. Policy changes are needed to promote IQ assessment to ensure high-quality clinical encounters during which interventions are effectively delivered. CLINICAL RELEVANCE: In both research and practice settings, the conceptualization and measurement of IQ will improve patient outcomes by advancing translational science and integrating evidence-based interventions into nursing practice.

Designed Cultural Adaptation and Delivery Quality in Rural Substance Use Prevention: an Effectiveness Trial for the Keepin' it REAL Curriculum.

This study examined how cultural adaptation and delivery quality of the school-based intervention keepin' it REAL (kiR) influenced adolescent substance use. The goal of the study was to compare the effectiveness of the multi-cultural, urban (non-adapted) kiR intervention, a re-grounded (adapted) rural version of the kiR intervention and control condition in a new, rural setting. A total of 39 middle schools in rural communities of two states in the USA were randomly assigned to one of three conditions (i.e., control, non-adapted urban kiR, and adapted rural kiR). Data included adolescent self-reported lifetime substance use and observers' ratings of delivery quality from video recordings of lessons. Ratings of delivery quality were used to create four comparison groups (i.e., low/high delivery quality in non-adapted/urban kiR condition and low/high quality in adapted/rural kiR condition). Controlling for substance use in the 7th grade, findings compared 9th graders' (N = 2781) lifetime alcohol, cigarette, marijuana, and chewing tobacco use. Mixed model analyses revealed that rural youth receiving the culturally adapted/rural curriculum reported significantly less cigarette use than rural youth in the control condition regardless of delivery quality. In the non-adapted/urban condition, youth receiving high delivery quality delivery reported less marijuana use than those receiving low delivery quality condition. However, substance use outcomes of youth receiving high and low delivery quality in the non-adapted intervention did not differ significantly from those the control group. Findings support the effectiveness of the culturally adapted/rural keepin' it REAL curriculum for rural youth.

Social Interface Model: Theorizing Ecological Post-Delivery Processes for Intervention Effects.

Successful prevention programs depend on a complex interplay among aspects of the intervention, the participant, the specific intervention setting, and the broader set of contexts with which a participant interacts. There is a need to theorize what happens as participants bring intervention ideas and behaviors into other life-contexts, and theory has not yet specified how social interactions about interventions may influence outcomes. To address this gap, we use an ecological perspective to develop the social interface model. This paper presents the key components of the model and its potential to aid the design and implementation of prevention interventions. The model is predicated on the idea that intervention message effectiveness depends not only on message aspects but also on the participants' adoption and adaptation of the message vis-à-vis their social ecology. The model depicts processes by which intervention messages are received and enacted by participants through social processes occurring within and between relevant microsystems. Mesosystem interfaces (negligible interface, transference, co-dependence, and interdependence) can facilitate or detract from intervention effects. The social interface model advances prevention science by theorizing that practitioners can create better quality interventions by planning for what occurs after interventions are delivered.

Parental Messages about Substance Use in Early Adolescence: Extending a Model of Drug-Talk Styles.

This study extends a typology of parent-offspring drug talk styles to early adolescents and investigates associations with adolescent substance use. Data come from a self-report survey associated with a school-based, 7th grade drug prevention curriculum. Mixed methods were used to collect data across four measurement occasions spanning 30 months. Findings highlight the frequencies of various drug-talk styles over time (i.e., situated direct, ongoing direct, situated indirect, ongoing indirect, never talked), messages adolescents hear from parents, and comparisons of alcohol, cigarette, and marijuana use by drug-talk style. This study advances an understanding of parent-adolescent communication about substances and holds practical implications for drug prevention efforts.

Parent Prevention Communication Profiles and Adolescent Substance Use: A Latent Profile Analysis and Growth Curve Model.

This current study identifies distinct parent prevention communication profiles and examines whether youth with different parental communication profiles have varying substance use trajectories over time. Eleven schools in two rural school districts in the Midwestern United States were selected, and 784 students were surveyed at three time points from the beginning of 7th grade to the end of 8th grade. A series of latent profile analyses were performed to identify discrete profiles/subgroups of substance-specific prevention communication (SSPC). The results revealed a 4-profile model of SSPC: Active-Open, Passive-Open, Active-Silent, and Passive-Silent. A growth curve model revealed different rates of lifetime substance use depending on the youth's SSPC profile. These findings have implications for parenting interventions and tailoring messages for parents to fit specific SSPC profiles.

Teacher Narratives and Student Engagement: Testing Narrative Engagement Theory in Drug Prevention Education.

Testing narrative engagement theory, this study examines student engagement and teachers' spontaneous narratives told in a narrative-based drug prevention curriculum. The study describes the extent to which teachers share their own narratives in a narrative-based curriculum, identifies dominant narrative elements, forms and functions, and assesses the relationships among teacher narratives, overall lesson narrative quality, and student engagement. One hundred videotaped lessons of the keepin' it REAL drug prevention curriculum were coded and the results supported the claim that increased narrative quality of a prevention lesson would be associated with increased student engagement. The quality of narrativity, however, varied widely. Implications of these results for narrative-based prevention interventions and narrative pedagogy are discussed.

Resisting pressure from peers to engage in sexual behavior: What communication strategies do early adolescent Latino Girls use?

A content analysis of early adolescent (M=12.02 years) Latino girls' (n=44) responses to open-ended questions imbedded in an electronic survey was conducted to explore strategies girls may use to resist peer pressure with respect to sexual behavior. Analysis yielded 341 codable response units, 74% of which were consistent with the REAL typology (i.e., refuse, explain, avoid, and leave) previously identified in adolescent substance use research. However, strategies reflecting a lack of resistance (11%) and inconsistency with communication competence (e.g., aggression, involving authorities) were also noted (15%). Frequency of particular strategies varied according to offer type, suggesting a variety of strategies may be needed to resist the peer pressure that puts early adolescent girls at risk for engaging in sexual behavior. Findings argue for universality of the REAL typology, building communication competence skills for conflict resolution in dating situations, and including peer resistance strategies in adolescent pregnancy prevention programs.

Adherence and delivery: implementation quality and program outcomes for the seventh-grade keepin' it REAL program.

Poor implementation quality (IQ) is known to reduce program effects making it important to consider IQ for evaluation and dissemination of prevention programs. However, less is known about the ways specific implementation variables relate to outcomes. In this study, two versions of keepin' it REAL, a seventh-grade drug prevention intervention, were implemented in 78 classrooms in 25 schools in rural districts in Pennsylvania and Ohio. IQ was measured through observational coding of 276 videos. IQ variables included adherence to the curriculum, teacher engagement (attentiveness, enthusiasm, seriousness, clarity, positivity), student engagement (attention, participation), and a global rating of teacher delivery quality. Factor analysis showed that teacher engagement, student engagement, and delivery quality formed one factor, which was labeled delivery. A second factor was adherence to the curriculum. Self-report student surveys measured substance use, norms (beliefs about prevalence and acceptability of use), and efficacy (beliefs about one's ability to refuse substance offers) at two waves (pretest, immediate posttest). Mixed model regression analysis which accounted for missing data and controlled for pretest levels examined implementation quality's effects on individual level outcomes, statistically controlling for cluster level effects. Results show that when implemented well, students show positive outcomes compared to students receiving a poorly implemented program. Delivery significantly influenced substance use and norms, but not efficacy. Adherence marginally significantly predicted use and significantly predicted norms, but not efficacy. Findings underscore the importance of comprehensively measuring and accounting for IQ, particularly delivery, when evaluating prevention interventions.

Typology of delivery quality: latent profile analysis of teacher engagement and delivery techniques in a school-based prevention intervention, keepin' it REAL curriculum.

Enhancing the delivery quality of school-based, evidence-based prevention programs is one key to ensuring uniform program effects on student outcomes. Program evaluations often focus on content dosage when implementing prevention curricula, however, less is known about implementation quality of prevention content, especially among teachers who may or may not have a prevention background. The goal of the current study is to add to the scholarly literature on implementation quality for a school-based substance use prevention intervention. Twenty-five schools in Ohio and Pennsylvania implemented the original keepin' REAL (kiR) substance use prevention curriculum. Each of the 10, 40-45 min lessons of the kiR curriculum was video recorded. Coders observed and rated a random sample of 276 videos reflecting 78 classes taught by 31 teachers. Codes included teachers' delivery techniques (e.g., lecture, discussion, demonstration and role play) and engagement with students (e.g. attentiveness, enthusiasm and positivity). Based on the video ratings, a latent profile analysis was run to identify typology of delivery quality. Five profiles were identified: holistic approach, attentive teacher-orientated approach, enthusiastic lecture approach, engaged interactive learning approach and skill practice-only approach. This study provides a descriptive typology of delivery quality while implementing a school-based substance use prevention intervention.

Random assignment of schools to groups in the drug resistance strategies rural project: some new methodological twists.

Random assignment to groups is the foundation for scientifically rigorous clinical trials. But assignment is challenging in group randomized trials when only a few units (schools) are assigned to each condition. In the DRSR project, we assigned 39 rural Pennsylvania and Ohio schools to three conditions (rural, classic, control). But even with 13 schools per condition, achieving pretest equivalence on important variables is not guaranteed. We collected data on six important school-level variables: rurality, number of grades in the school, enrollment per grade, percent white, percent receiving free/assisted lunch, and test scores. Key to our procedure was the inclusion of school-level drug use data, available for a subset of the schools. Also, key was that we handled the partial data with modern missing data techniques. We chose to create one composite stratifying variable based on the seven school-level variables available. Principal components analysis with the seven variables yielded two factors, which were averaged to form the composite inflate-suppress (CIS) score which was the basis of stratification. The CIS score was broken into three strata within each state; schools were assigned at random to the three program conditions from within each stratum, within each state. Results showed that program group membership was unrelated to the CIS score, the two factors making up the CIS score, and the seven items making up the factors. Program group membership was not significantly related to pretest measures of drug use (alcohol, cigarettes, marijuana, chewing tobacco; smallest p > .15), thus verifying that pretest equivalence was achieved.

From kids, through kids, to kids: examining the social influence strategies used by adolescents to promote prevention among peers.

Recent technological advances have increased the interest and ability of lay audiences to create messages; however, the feasibility of incorporating lay multimedia messages into health campaigns has seldom been examined. Drawing on the principle of cultural grounding and narrative engagement theory, this article seeks to examine what types of messages adolescents believe are most effective in persuading their peers to resist substance use and to provide empirical data on the extent to which audience-generated intervention messages are consistent with the associated campaign philosophy and branding. Data for the current study are prevention messages created by students as part of a four-lesson substance use prevention "booster" program delivered to eighth-grade students in 20 rural schools in Pennsylvania and Ohio during 2010-2011. Content analysis results indicate that didactic message strategies were more common in audience-generated messages than narrative strategies, although strategy was somewhat dependent on the medium used. Two of the most common strategies that adolescents used to persuade peers not to use substances were negative consequences and identity appeals, and messages varied in the degree to which they were consistent with the theoretical underpinnings and program philosophy of the prevention campaign. Implications of the current study for understanding the social construction of substance use prevention messages among adolescents and incorporating audience-generated messages in health communication campaigns are discussed.

Adapting school-based substance use prevention curriculum through cultural grounding: a review and exemplar of adaptation processes for rural schools.

A central challenge facing twenty-first century community-based researchers and prevention scientists is curriculum adaptation processes. While early prevention efforts sought to develop effective programs, taking programs to scale implies that they will be adapted, especially as programs are implemented with populations other than those with whom they were developed or tested. The principle of cultural grounding, which argues that health message adaptation should be informed by knowledge of the target population and by cultural insiders, provides a theoretical rational for cultural regrounding and presents an illustrative case of methods used to reground the keepin' it REAL substance use prevention curriculum for a rural adolescent population. We argue that adaptation processes like those presented should be incorporated into the design and dissemination of prevention interventions.

Describing teacher-student interactions: a qualitative assessment of teacher implementation of the 7th grade keepin' it REAL substance use intervention.

Variations in the delivery of school-based substance use prevention curricula affect students' acquisition of the lesson content and program outcomes. Although adaptation is sometimes viewed as a lack of fidelity, it is unclear what types of variations actually occur in the classroom. This observational study investigated teacher and student behaviors during implementation of a middle school-based drug prevention curriculum in 25 schools across two Midwestern states. Trained observers coded videos of 276 lessons, reflecting a total of 31 predominantly Caucasian teachers (10 males and 21 females) in 73 different classes. Employing qualitative coding procedures, the study provides a working typology of implementation patterns based on varying levels of teacher control and student participation. These patterns are fairly consistent across lessons and across classes of students, suggesting a teacher-driven delivery model where teachers create a set of constraints within which students vary their engagement. Findings provide a descriptive basis grounded in observation of classroom implementation that can be used to test models of implementation fidelity and quality as well as impact training and other dissemination research.