A Translational Case Study of a Multisite COVID-19 Public Health Intervention Across Sequenced Research Trials: Embedding Implementation in a Community Engagement Phased Framework.

Through a COVID-19 public health intervention implemented across sequenced research trials, we present a community engagement phased framework that embeds intervention implementation: (1) consultation and preparation, (2) collaboration and implementation, and (3) partnership and sustainment. Intervention effects included mitigation of psychological distress and a 0.28 increase in the Latinx population tested for SARS-CoV-2. We summarize community engagement activities and implementation strategies that took place across the trials to illustrate the value of the framework for public health practice and research. (Am J Public Health. 2024;114(S5):S396-S401. https://doi.org/10.2105/AJPH.2024.307669).

Community Partner Perceptions of Equitable Implementation Practices for a Promotores de Salud Intervention: A Qualitative Assessment.

We conducted focus groups with staff from 5 community-based organizations (21 participants; 86% female, 52% Hispanic/Latino/a/x and 24% Mexican/Mexican American) between August and October 2021. Results highlighted community partner perceptions of practices congruent (e.g., communication that built trust and dismantled power dynamics, a shared mission) and incongruent (e.g., intervention-community misalignment, research driven decision-making) with equitable implementation in the development, implementation, and evaluation of a promotores de salud intervention to increase COVID-19 testing and preventive behaviors among Latinx communities in Oregon. (Am J Public Health. 2024;114(S5):S377-S383. https://doi.org/10.2105/AJPH.2024.307686).

Family Check-Up Online: Effects of a Virtual Randomized Trial on Parent Stress, Parenting, and Child Outcomes in Early Adolescence.

We adapted the Family Check-Up Online (FCU-O) (1) to support families coping with pandemic-related stressors to prevent behavioral and emotional problems among middle school youth and (2) for smartphone delivery to increase access and reach during the COVID-19 pandemic. This study evaluated the direct and indirect effects of the adapted FCU-O at 4-months post-baseline. The FCU-O combines online parenting support with telephone coaching. Participants were primary caregivers of children ages 10 to 14 years. Eligibility included endorsing depression on the PHQ-2 or significant stress on a 4-item version of the Perceived Stress Scale. We randomly assigned participants to the adapted FCU-O (N = 74) or a waitlist control condition (N = 87). Participants predominantly self-identified as female (95%), 42.77 years old on average, and White (84.6%). Outcomes included caregiver reports of perceived stress and parenting, and youth conduct problems and depressive symptoms. Using a multilevel modeling approach, we tested intent-to-treat intervention effects at 4-months, with time points nested within participants. The FCU-O reduced caregiver stress and improved proactive parenting and limit setting but had no effects on youth outcomes. Effect sizes were small to moderate (Cohen's d ranged from .37 to .57). We examined indirect effects on youth outcomes at 4-months via changes in caregiver stress and parenting at 2-months. Mediation analyses suggested indirect effects on youth depressive symptoms via reductions in caregiver stress and increases in proactive parenting. Results indicate the FCU-O has potential as a public health intervention for families facing extreme stressors such as those during the COVID-19 pandemic. ClinicalTrials.gov Identifier: NCT05117099.

Effects of a Health Education Intervention for COVID-19 Prevention in Latinx Communities: A Cluster-Randomized Controlled Trial.

To promote COVID-19 preventive attitudes and behaviors among Latinx individuals, researchers and community partners implemented a culturally tailored health education intervention across 12 Oregon counties from February 2021 through April 2022. We did not identify any significant intervention effects on preventive attitudes and behaviors but did observe significant decreases in psychological distress. Although Latinx individuals' preventive attitudes and behaviors were not associated with the health education intervention, findings suggest the intervention has value in promoting their well-being (ClinicalTrials.gov Identifier: NCT04793464). (Am J Public Health. 2022;112(S9):S923-S927. https://doi.org/10.2105/AJPH.2022.307129).

Motivational Interviewing and Caregiver Engagement in the Family Check-Up 4 Health.

Motivational interviewing (MI) is a therapeutic style in which a provider elicits client motivation and helps strengthen commitment to change (Miller and Rollnick 2002). The original Family Check-Up (FCU; Dishion and Stormshak 2007)-and the adapted version for improving health behaviors in primary care, the Family Check-Up 4 Health (FCU4Health; Smith et al. 2018a)-are brief, assessment-driven, and family-centered preventive interventions that use MI to improve parent engagement in services to improve parenting and prevent negative child outcomes. This study examines the role of MI in the Raising Healthy Children project, a randomized trial to test the effectiveness of the FCU4Health for the prevention of obesity in pediatric primary care, with data from the 141 families assigned to receive the FCU4Health. Families were eligible for the study if the child was between 5.5 and 12 years of age at the time of identification and had a BMI ≥ 85th percentile for age and gender at the most recent visit to their primary care provider. MI skills at the first session predicted caregiver in-session active engagement, attendance at follow-up parenting sessions, and improvements in motivation to address child health and behavior goals. Baseline characteristics of the family (i.e., child health diagnosis, caregiver baseline depression, motivation, and Spanish language preference) had differential associations with responsiveness and MI skills. This study has implications for program development, provider training, and fidelity monitoring.

Facilitators and Barriers in Cross-Country Transport of Evidence-based Preventive Interventions: a Case Study Using the Family Check-Up.

This study is a qualitative analysis of facilitators and barriers in the dissemination of Family Check-Up (FCU), a U.S.-developed preventive intervention in Sweden. The FCU is inherently culturally flexible because it was designed to be tailored to each family's needs and context, including cultural norms and values. We present the FCU implementation framework (IF) as a conceptual framework for cross-country transport of the FCU and evidence-based programs (EBP) more generally. The FCU IF draws from implementation science literature and involves specifying barriers and facilitators related to implementation drivers (e.g., competency) at each implementation phase and applying these data to inform phase-specific, readiness-building activities for each driver. In addition to driver-related influences, barriers and facilitators specific to the FCU and the collaborative partnership between the U.S. and Swedish purveyors emerged in the data. The partnership's reliance on a hybrid bottom-up, top-down approach that balanced the Swedish purveyor's autonomy and cultural expertise with guidance from the U.S. purveyor facilitated adaptation of the FCU for Sweden. Relying on previously collected data, we also explored similarities and differences in barriers and facilitators to FCU scale-up in the United States versus Sweden. In general, across drivers, the same barriers and facilitators were salient. This study suggests that dissemination of culturally flexible EBPs guided by a dynamic implementation framework can facilitate cross-country transport of EBPs. This study promotes a culture of prevention by highlighting barriers, facilitators, and readiness-building strategies that influence the cross-cultural transportability of EBPs that prevent the onset and escalation of child problem behavior.

Effects of the Family Check-Up 4 Health on Parenting and Child Behavioral Health: A Randomized Clinical Trial in Primary Care.

The Family Check-Up 4 Health (FCU4Health) is an adaptation of the Family Check-Up (FCU) for delivery in primary care settings. While maintaining the original FCU's focus on parenting and child behavioral health, we added content targeting health behaviors. This study evaluated whether the adapted FCU maintained positive effects on parenting (positive behavior support, limit setting, parental warmth) and child behavioral health (self-regulation, conduct problems, emotional problems). Pediatric (6-12 years) primary care patients with a BMI ≥ 85th%ile (n = 240) were recruited from primary care clinics in Phoenix. Children were 75% Latino, 49% female, and 73% Medicaid recipients. This type 2 effectiveness-implementation hybrid trial compared families randomized to FCU4Health (n = 141) or usual care (n = 99). FCU4Health was delivered over a period of 6 months. This study focuses on a priori secondary outcomes included parenting and child behavioral health targets of the original FCU, assessed at baseline and 3, 6, and 12 months. Significant improvements were found for the FCU4Health condition, compared to usual care, in parenting from baseline to the 3-month assessment [ß = .17 (.01; .32)]. Parenting predicted improvements in child self-regulation at 6-months [ß = .17 (.03; .30)], which in turn predicted reductions in conduct problems [ß = - .38 (- .51; - .23)] and emotional problems [ß = - .24 (- .38; - .09)] at 12 months. Ethnicity and language of delivery (English or Spanish) did not moderate these effects. The FCU4Health can improve parenting and child behavioral health outcomes when delivered in primary care.Trial Registration Trial registration number: NCT03013309 ClinicalTrials.gov.

Provider Readiness and Adaptations of Competency Drivers During Scale-Up of the Family Check-Up.

We used provider (n = 112) data that staff at the agency disseminating the Family Check-Up (FCU; REACH Institute) collected to profile provider diversity in community settings and to examine whether provider profiles are related to implementation fidelity. Prior to FCU training, REACH Institute staff administered the FCU Provider Readiness Assessment (PRA), a provider self-report measure that assesses provider characteristics previously linked with provider uptake of evidence-based interventions. We conducted a latent class analysis using PRA subscale scores as latent class indicators. Results supported four profiles: experienced high readiness (ExHR), experienced low readiness (ExLR), moderate experience (ME), and novice. The ExHR class was higher than all other classes on: (1) personality variables (i.e., agreeableness, conscientiousness, openness, extraversion); (2) evidence-based practice attitudes; (3) work-related enthusiasm and engagement; and (4) their own well-being. The ExHR class was also higher than ExLR and ME classes on clinical flexibility. The ME class was lowest of all classes on conscientiousness, supervision, clinical flexibility, work-related enthusiasm and engagement, and well-being. During the FCU certification process, FCU Consultants rated providers' fidelity to the model. Twenty-three of the 112 providers that completed the PRA also participated in certification. We conducted follow-up regression analyses using fidelity data for these 23 providers to explore associations between probability of class membership and fidelity. The likelihood of being in the ExHR class was related to higher FCU fidelity, whereas the likelihood of being in the ExLR class was related to lower fidelity. We discuss how provider readiness assessment data can be used to guide the adaptation of provider selection, training, and consultation in community settings.

Redesigning Implementation Measurement for Monitoring and Quality Improvement in Community Delivery Settings.

The field of prevention has established the potential to promote child adjustment across a wide array of outcomes. However, when evidence-based prevention programs have been delivered at scale in community settings, declines in implementation and outcomes have resulted. Maintaining high quality implementation is a critical challenge for the field. We describe steps towards the development of a practical system to monitor and support the high-quality implementation of evidence-based prevention programs in community settings. Research on the implementation of an evidence-based parenting program for divorcing families called the "New Beginnings Program" serves as an illustration of the promise of such a system. As a first step, we describe a multidimensional theoretical model of implementation that links aspects of program delivery with improvements in participant outcomes. We then describe research on the measurement of each of these implementation dimensions and test their relations to intended program outcomes. As a third step, we develop approaches to the assessment of these implementation constructs that are feasible to use in community settings and to establish their reliability and validity. We focus on the application of machine learning algorithms and web-based data collection systems to assess implementation and provide support for high quality delivery and positive outcomes. Examples are presented to demonstrate that valid and reliable measures can be collected using these methods. Finally, we envision how these measures can be used to develop an unobtrusive system to monitor implementation and provide feedback and support in real time to maintain high quality implementation and program outcomes.

The Cascading Effects of Multiple Dimensions of Implementation on Program Outcomes: a Test of a Theoretical Model.

This study tests a theoretical cascade model in which multiple dimensions of facilitator delivery predict indicators of participant responsiveness, which in turn lead to improvements in targeted program outcomes. An effectiveness trial of the 10-session New Beginnings Program for divorcing families was implemented in partnership with four county-level family courts. This study included 366 families assigned to the intervention condition who attended at least one session. Independent observers provided ratings of program delivery (i.e., fidelity to the curriculum and process quality). Facilitators reported on parent attendance and parents' competence in home practice of program skills. At pretest and posttest, children reported on parenting and parents reported child mental health. We hypothesized effects of quality on attendance, fidelity and attendance on home practice, and home practice on improvements in parenting and child mental health. Structural Equation Modeling with mediation and moderation analyses were used to test these associations. Results indicated quality was significantly associated with attendance, and attendance moderated the effect of fidelity on home practice. Home practice was a significant mediator of the links between fidelity and improvements in parent-child relationship quality and child externalizing and internalizing problems. Findings provide support for fidelity to the curriculum, process quality, attendance, and home practice as valid predictors of program outcomes for mothers and fathers. Future directions for assessing implementation in community settings are discussed.

Attendance Patterns and Links to Non-Response on Child Report of Internalizing among Mexican-Americans Randomized to a Universal Preventive Intervention.

We examined attendance trajectory profiles among 335 Mexican-American families participating in an 11-week universal intervention to explore if heterogeneity in attendance and thus dosage was associated with intervention response, defined as pre-to-2-year post (T2) reductions in child report of internalizing symptoms. We estimated trajectories accounting for the influence of baseline covariates, selected based on the Health Belief Model (HBM) and Latino family research, to understand covariate associations with trajectories. Results supported six attendance trajectory groups: non-attenders (NA), early dropouts-low internalizing (EDO-LI), early dropouts-high internalizing (EDO-HI), mid-program dropouts (MPDO), sustained attenders-low internalizing (SA-LI), and sustained attenders-high internalizing (SA-HI). All groups except EDO-HI showed significant pre-to-post change on child report of internalizing; however, trajectory groups reflecting more attendance did not have greater pre-to-post change. Nonetheless, child report of internalizing differentiated two subgroups of sustained attenders and two subgroups of early dropouts. These results suggest heterogeneity among families with similar patterns of attendance and highlight the importance of modeling this heterogeneity. Although life stress was a barrier to participation, there was minimal support for the HBM. Cultural influences, acculturation, and familism, played a more prominent role in distinguishing trajectories. As expected, the EDO-HI group was less acculturated than both sustained attender groups and reported weaker familism values than the SA-HI group. However, unexpectedly, the SA-LI group had lower familism than the EDO-LI group. The results suggest that the influence of culture on participation is nuanced and may depend on child symptomatology.

Attendance Trajectory Classes Among Divorced and Separated Mothers and Fathers in the New Beginnings Program.

We examined attendance trajectories among mothers and fathers in the effectiveness trial of the New Beginnings Program, a parenting-focused prevention program for divorced and separated parents. We also investigated attendance trajectory class differences on two sets of pretest covariates: one set previously linked to participation in programs not specifically targeting divorced parents (i.e., sociodemographics, perceived parenting skills, child problem behaviors, parent psychological distress) and another that might be particularly salient to participation in the context of divorce (i.e., interparental conflict, level of parent-child contact, previous marital status to the ex-spouse). For mothers and fathers, results supported four attendance trajectory classes: (1) non-attenders (NA), (2) early dropouts (ED), (3) declining attenders (DA), and (4) sustained attenders (SA). In the final model testing multiple covariates simultaneously, mothers who were EDs and DAs were more likely to be Latina than SAs, and EDs reported more interparental conflict than SAs. Mother trajectory groups did not differ on parenting skills, child problem behavior, or mother-child contact in the final or preliminary models. In the final model for fathers, EDs rated their children higher on externalizing than DAs, had less contact with their children than DAs and NAs, and reported less distress than SAs. Father trajectory groups did not differ on fathers' age, ethnicity, income, perceived parenting skills, or interparental conflict in the final or preliminary models. Results highlight qualitatively distinct latent classes of mothers and fathers who disengage from a parenting intervention at various points. We discuss implications for intervention engagement strategies and translational science.

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

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

Ethical Challenges in Promoting the Implementation of Preventive Interventions: Report of the SPR Task Force.

Prevention science researchers and practitioners are increasingly engaged in a wide range of activities and roles to promote evidence-based prevention practices in the community. Ethical concerns invariably arise in these activities and roles that may not be explicitly addressed by university or professional guidelines for ethical conduct. In 2015, the Society for Prevention Research (SPR) Board of Directors commissioned Irwin Sandler and Tom Dishion to organize a series of roundtables and establish a task force to identify salient ethical issues encountered by prevention scientists and community-based practitioners as they collaborate to implement evidence-based prevention practices. This article documents the process and findings of the SPR Ethics Task Force and aims to inform continued efforts to articulate ethical practice. Specifically, the SPR membership and task force identified prevention activities that commonly stemmed from implementation and scale-up efforts. This article presents examples that illustrate typical ethical dilemmas. We present principles and concepts that can be used to frame the discussion of ethical concerns that may be encountered in implementation and scale-up efforts. We summarize value statements that stemmed from our discussion. We also conclude that the field of prevention science in general would benefit from standards and guidelines to promote ethical behavior and social justice in the process of implementing evidence-based prevention practices in community settings. It is our hope that this article serves as an educational resource for students, investigators, and Human Subjects Review Board members regarding some of the complexity of issues of fairness, equality, diversity, and personal rights for implementation of preventive interventions.

School engagement mediates long-term prevention effects for Mexican American adolescents.

This 5-year follow-up of a randomized clinical trial evaluated the efficacy of a family-focused intervention delivered in middle school to increase school engagement following transition to high school (2 years post-test), and also evaluated mediated effects through school engagement on multiple problem outcomes in late adolescence (5 years post-test). The study sample included 516 Mexican American adolescents who participated in a randomized trial of the Bridges to High School Program (Bridges/Puentes). Path models representing the direct and indirect effects of the program on four outcome variables were evaluated using school engagement measured in the 9th grade as a mediator. The program significantly increased school engagement, with school engagement mediating intervention effects on internalizing symptoms, adolescent substance use, and school dropout in late adolescence when most adolescents were in the 12th grade. Effects on substance use were stronger for youth at higher risk based on pretest report of substance use initiation. There were no direct or indirect intervention effects on externalizing symptoms. Findings support that school engagement is an important prevention target for Mexican American adolescents.

Participation patterns among Mexican-American parents enrolled in a universal intervention and their association with child externalizing outcomes.

This study used growth mixture modeling to examine attendance trajectories among 292 Mexican-American primary female caregivers enrolled in a universal preventive intervention and the effects of health beliefs, participation intentions, cultural influences, and intervention group cohesion on trajectory group membership as well as trajectory group differences on a distal outcome, immediate posttest teacher report of child externalizing (T2). Results supported four trajectory groups-early terminators (ET), mid-program terminators (MPT), low-risk persistent attenders (LRPA), and high-risk persistent attenders (HRPA). Compared with LRPAs, caregivers classified as HRPAs had weaker familism values, less parenting efficacy, and higher externalizing children with lower GPAs. Caregivers in the two persistent attender groups reported strong group cohesion and providers rated these caregivers as having strong participation intentions. Children of caregivers in the LRPA group had the lowest T2 child externalizing. Children of caregivers in the MPT group had lower T2 externalizing than did those of the ET group, suggesting partial intervention dosage can benefit families. Despite high levels of attendance, children of caregivers in the HRPA had the highest T2 externalizing, suggesting this high-risk group needed either more intensive services or a longer period for parents to implement program skills to evidence change in child externalizing.

Colocation of COVID-19 Vaccination Services at Syringe Service Programs for People Who Inject Drugs and People Experiencing Houselessness in Oregon.

OBJECTIVES: Integrating vaccination services with other essential health services could increase vaccination rates among socially marginalized populations. We examined the associations between colocation of vaccines at syringe service programs and COVID-19 vaccination status among people who inject drugs and people experiencing houselessness. METHODS: This study included 1891 participants aged ≥18 years at 9 sites in Oregon from July 2021 through March 2022. Participants self-reported whether they had ever received ≥1 dose of a COVID-19 vaccine. We calculated site-level COVID-19 vaccine availability and overall vaccination rates. We compared site-level vaccination rates and analyzed the association between vaccine availability and vaccination status. RESULTS: We found no significant difference in vaccination rates between sites that did and did not offer COVID-19 vaccines (t7 = -0.33; P = .75). We also found no significant association between vaccine availability and vaccination status. However, the odds of having received a COVID-19 vaccine were 2.79 times higher for each additional site visit during which COVID-19 vaccines were available (odds ratio [OR] = 2.79; 95% CI, 2.18-3.58; P < .001). The association between vaccine availability and vaccine status was not moderated by participant age (OR = 1.03; 95% CI, 0.99-1.07; P = .13) or housing instability (OR = 0.59; 95% CI, 0.13-2.60; P = .48). CONCLUSIONS: Colocating COVID-19 vaccines at syringe service programs was only positively associated with vaccination status if vaccines were offered frequently on-site. Future work should examine whether the frequency of offering vaccination services increases willingness to engage in vaccination and examine trust and convenience as potential mechanisms.

A Digital Health Model for School-Based Implementation to Improve Parent and Child Outcomes: Comparison of Active Versus Light-Touch Coaching Effects.

Online or app-based parenting interventions have become more widely available in recent years. However, challenges related to poor engagement and high attrition have been noted in the literature, and there are important questions regarding ways to enhance parental engagement and improve treatment outcomes through digital health, including through the addition of therapeutic coaches. The current study evaluated differences in the effects of active versus "light-touch" coaching implementations of an enhanced version of Family Check-Up Online (FCU-O) on parent/family and child-level outcomes from pre-treatment to 2-month follow-up assessments. The enhanced version of the FCU-O was adapted to support families in coping with pandemic-related stressors to prevent youth behavioral and emotional problems during middle school and included app-based modules designed to support effective parenting practices as well as virtual coaching. In the "active-coach" condition, parenting coaches were active in efforts to arrange coaching sessions with parents as they worked through the app-based modules, while in the light-touch intervention, parent-coaches enrolled participants in the context of a one-time support session but did not actively pursue families to schedule additional sessions. Parents in the active-coach condition exhibited greater engagement with both the app and coaching sessions than parents in the light-touch condition. Further, stronger improvements in several aspects of parenting and child functioning were observed in the active-coach versus light-touch conditions. However, parents in the light-touch condition showed reductions in stress and comparable levels of dosage when using the app. Implications for prevention and accessibility of digital health interventions are discussed.

COVID-19 vaccine deliberation among people who inject drugs.

Background: People who inject drugs (PWID) are at greater risk for severe morbidity and mortality associated with COVID-19 due to comorbid, chronic, medical conditions and structural inequities associated with housing instability and incarceration. As such, they are a population that would greatly benefit from COVID-19 vaccination. Methods: We surveyed 350 syringe exchange clients between March 2021 and June 2021 to collect information on vaccine uptake among PWID, facilitators and barriers to vaccination, and demographic correlates of vaccine hesitancy. Results: Findings highlight that among PWID, vaccination access was remarkably low with only 10% of the sample receiving a COVID-19 vaccine. Vaccine acceptability among people who were vaccinated was 42% highlighting barriers to access. Motivation for vaccination included a desire to keep family members and other community members safe and a desire to feel safe around other people. Barriers to vaccination included concerns about vaccine side effects, lack of concern surrounding the effects of COVID-19, and insufficient information about how the vaccine works, along with general distrust of the vaccine development and deployment process. Conclusions: There is a need for structural interventions and individual behavioral interventions to improve COVID-19 vaccine access and uptake among PWID. Limitations and implications for next steps and future directions are discussed.