Clinician Perspectives on Suicide Safety Planning and Its Implementation.

OBJECTIVE: The safety planning intervention is an evidence-based practice shown to reduce suicide risk, but implementation of high-quality safety planning has proven challenging. We aimed to understand clinician perspectives on the safety planning intervention to inform future implementation efforts. METHOD: This cross-sectional survey of clinicians who care for patients at risk of suicide in an academic medical center asked about comfort levels and fidelity to components of the safety planning intervention and assessed implementation barriers and facilitators. We used exploratory data analysis and regression analysis to explore clinician perspectives and assess the relationship between formal training and implementation. RESULTS: Ninety-two clinicians responded to the survey. Two-thirds of participants (64.9%) endorsed using all six core elements of the safety planning intervention. Participants who reported receiving formal training in safety planning were significantly more likely to report being comfortable completing a safety plan (p < .001); those with higher levels of comfort were significantly more likely to endorse using all of the core elements of the safety planning intervention (p < .001). CONCLUSIONS: Training in the evidence-based safety planning intervention is associated with clinician comfort and awareness of the core elements of the intervention. Our results suggest that there are gaps in clinician training and that formal safety planning intervention training could have a positive effect on clinician comfort and treatment fidelity.

Baseline Sociodemographic Characteristics and Mental Health Status of Primary Caregivers and Children Attending Schools on the Navajo Nation During COVID-19.

BACKGROUND: Despite historical and contemporary trauma, American Indian and Alaska Native (AIAN; Indigenous) communities responded with resilience to the COVID-19 pandemic. However, AIANs experienced disproportionate rates of infection, hospitalization, death, and reduced life expectancy. School closures exacerbated disparities, leading to learning loss, economic instability, and mental health challenges among AIAN youth. METHODS: The Project SafeSchools cohort study employed a comprehensive longitudinal convergent mixed-methods approach, integrating community-based participatory research principles. The study enrolled Navajo Nation caregivers whose children were eligible to attend local reservation-based schools. We conducted an analysis of caregiver self-report baseline data collected between August 2021 and May 2022. RESULTS: A total of 242 caregivers completed at least part of the baseline assessment and were included in data analysis. Caregivers were primarily female (88.7%), non-Hispanic (97%), and Indigenous (97%). Most caregivers were in their late 30s (mean age 38), with varying educational backgrounds and employment statuses. Children were evenly split between males and females and distributed across different age groups. Most children attended school at baseline in various formats, including in-person, hybrid, and online-only settings. Caregivers reported a range of psychosocial and behavioral risks, including general mental distress, depressive symptoms, and anxiety for themselves and their children. Furthermore, caregivers and children exhibited various protective factors, such as strong cultural identity, resilience, and academic self-efficacy. CONCLUSIONS: This study highlights the higher rates of mental health distress among participating caregivers and children compared to national averages. Despite these challenges, cultural protective factors remained strong and should guide future crisis response efforts.

Honoring our teachings: children's storybooks as indigenous public health practice.

Introduction: American Indian and Alaska Native (AIAN) communities continue to flourish and innovate in the face of the COVID-19 pandemic. Storytelling is an important tradition for AIAN communities that can function as an intervention modality. To support the needs of AIAN children and caregivers, we (a collaborative workgroup of Indigenous health researchers) developed a culturally grounded storybook that provides pandemic-related public health guidance and mental health coping strategies woven with Inter-Tribal values and teachings. Methods: A collaborative workgroup, representing diverse tribal affiliations, met via four virtual meetings in early 2021 to discuss evolving COVID-19 pandemic public health guidance, community experiences and responses to emerging challenges, and how to ground the story in shared AIAN cultural strengths. We developed and distributed a brief survey for caregivers to evaluate the resulting book. Results: The workgroup iteratively reviewed versions of the storyline until reaching a consensus on the final text. An AI artist from the workgroup created illustrations to accompany the text. The resulting book, titled Our Smallest Warriors, Our Strongest Medicine: Honoring Our Teachings during COVID-19 contains 46 pages of text and full-color illustrations. An online toolkit including coloring pages, traditional language activities, and caregiver resources accompanies the book. We printed and distributed 50,024 physical copies of the book and a free online version remains available. An online survey completed by N = 34 caregivers who read the book with their child(ren) showed strong satisfaction with the book and interest in future books. Discussion: The development of this storybook provides insights for creative dissemination of future public health initiatives, especially those geared toward AIAN communities. The positive reception and widespread interest in the storybook illustrate how braiding AIAN cultural teachings with public health guidance can be an effective way to disseminate health information. This storybook highlights the importance of storytelling as an immersive learning experience through which caregivers and children connect to family, community, culture, and public health guidance. Culturally grounded public health interventions can be effective and powerful in uplifting AIAN cultural values and promoting health and well-being for present and future generations.

A qualitative study of mental health problems among children living in New Delhi slums.

Children living in urban slums in India are exposed to chronic stressors that increase their risk of developing mental disorders, but they remain a neglected group. Effective mental health interventions are needed; however, it is necessary to understand how mental health symptoms and needs are perceived and prioritized locally to tailor interventions for this population. We used an existing rapid ethnographic assessment approach to identify mental health problems from the perspective of children living in Indian slums, including local descriptions, perceived causes, impact, and coping behavior. Local Hindi-speaking interviewers conducted 77 free-list interviews and 33 key informant interviews with children and adults (N = 107) from two slums in New Delhi. Results identified a range of internalizing and externalizing symptoms consistent with depression, anxiety, and conduct problems in children. Findings included both common cross-cultural experiences and symptoms as well as uniquely described symptoms (e.g., "madness or anger," "pain in the heart and mind") not typically included on western standardized measures of psychopathology. Mental health problems appeared to be highly interconnected, with experiences such as harassment and fighting often described as both causes and impacts of mental health symptoms in children. Community perspectives indicated that even in the face of several unmet basic needs, mental health problems were important to the community and counseling interventions were likely to be acceptable. We discuss implications for adapting mental health interventions and assessing their effectiveness to reduce the burden of mental illness among children living in urban slums in India.

Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities.

The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.

Structural violence of racism and colonization are social determinants of suicide.Collaborative and power-sharing implementation strategies can disrupt oppression.Strengths-based collectivist strategies can buffer structural suicide risk.

Acceptability and Feasibility of a Smartphone-Based Real-Time Assessment of Suicide Among Black Men: Mixed Methods Pilot Study.

BACKGROUND: Suicide rates in the United States have increased recently among Black men. To address this public health crisis, smartphone-based ecological momentary assessment (EMA) platforms are a promising way to collect dynamic, real-time data that can help improve suicide prevention efforts. Despite the promise of this methodology, little is known about its suitability in detecting experiences related to suicidal thoughts and behavior (STB) among Black men. OBJECTIVE: This study aims to clarify the acceptability and feasibility of using smartphone-based EMA through a pilot study that assesses the user experience among Black men. METHODS: We recruited Black men aged 18 years and older using the MyChart patient portal messaging (the patient-facing side of the Epic electronic medical record system) or outpatient provider referrals. Eligible participants self-identified as Black men with a previous history of STB and ownership of an Android or iOS smartphone. Eligible participants completed a 7-day smartphone-based EMA study. They received a prompt 4 times per day to complete a brief survey detailing their STB, as well as proximal risk factors, such as depression, social isolation, and feeling like a burden to others. At the conclusion of each day, participants also received a daily diary survey detailing their sleep quality and their daily experiences of everyday discrimination. Participants completed a semistructured exit interview of 60-90 minutes at the study's conclusion. RESULTS: In total, 10 participants completed 166 EMA surveys and 39 daily diary entries. A total of 4 of the 10 participants completed 75% (21/28) or more of the EMA surveys, while 9 (90%) out of 10 completed 25% (7/28) or more. The average completion rate of all surveys was 58% (20.3/35), with a minimum of 17% (6/35) and maximum of 100% (35/35). A total of 4 (40%) out of 10 participants completed daily diary entries for the full pilot study. No safety-related incidents were reported. On average, participants took 2.08 minutes to complete EMA prompts and 2.72 minutes for daily diary surveys. Our qualitative results generally affirm the acceptability and feasibility of the study procedures, but the participants noted difficulties with the technology and the redundancy of the survey questions. Emerging themes also addressed issues such as reduced EMA survey compliance and diminished mood related to deficit-framed questions related to suicide. CONCLUSIONS: Findings from this study will be used to clarify the suitability of EMA for Black men. Overall, our EMA pilot study demonstrated mixed feasibility and acceptability when delivered through smartphone-based apps to Black men. Specific recommendations are provided for managing safety within these study designs and for refinements in future intervention and implementation science research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/31241.

Implementation measurement in global mental health: Results from a modified Delphi panel and investigator survey.

Limited guidance exists to support investigators in the choice, adaptation, validation and use of implementation measures for global mental health implementation research. Our objectives were to develop consensus on best practices for implementation measurement and identify strengths and opportunities in current practice. We convened seven expert panelists. Participants rated approaches to measure adaptation and validation according to appropriateness and feasibility. Follow-up interviews were conducted and a group discussion was held. We then surveyed investigators who have used quantitative implementation measures in global mental health implementation research. Participants described their use of implementation measures, including approaches to adaptation and validation, alongside challenges and opportunities. Panelists agreed that investigators could rely on evidence of a measure's validity, reliability and dimensionality from similar contexts. Panelists did not reach consensus on whether to establish the pragmatic qualities of measures in novel settings. Survey respondents (n = 28) most commonly reported using the Consolidated Framework for Implementation Research Inner Setting Measures (n = 9) and the Program Assessment Sustainability Tool (n = 5). All reported adapting measures to their settings; only two reported validating their measures. These results will support guidance for implementation measurement in support of mental health services in diverse global settings.

Summarizing Implementation Support for School-Based COVID-19 Testing Programs in Southwest American Indian Communities.

CONTEXT: American Indian communities have been disproportionately affected by the COVID-19 pandemic, with school closures exacerbating health and education disparities. PROGRAM: Project SafeSchools' COVID-19 school-based testing program utilized federal and state funding to provide weekly pooled testing with follow-up rapid antigen testing to students and staff from the White Mountain Apache Tribe and Navajo Nation. IMPLEMENTATION: The project provided partner schools with training and continual logistical and technical support to aid in school-based testing and adherence to state and local reporting requirements. EVALUATION: Using the EPIS (Exploration, Preparation, Implementation, and Sustainment) framework, we identified facilitators and barriers to successful program function. While community support and buy-in were essential for successfully implementing school-based testing in these communities, communication, school staff turnover, and funding are among the most significant challenges. DISCUSSION: Community partnerships in American Indian communities involving schools and local health authorities can successfully implement testing protocols by remaining flexible and working together to maintain strong lines of communication.

Demographic predictors of emergency service utilization patterns in youth at risk of suicide.

OBJECTIVE: To explore demographic predictors of Emergency Department (ED) utilization among youth with a history of suicidality (i.e., ideation or behaviors). METHODS: Electronic health records were extracted from 2017 to 2021 for 3094 8-22 year-old patients with a history of suicidality at an urban academic medical center ED in the Mid-Atlantic. Logistic regression analyses were used to assess for demographic predictors of ED utilization frequency, timing of subsequent visits, and reasons for subsequent visits over a 24-month follow-up period. RESULTS: Black race (OR = 1.45, 95% CI = 1.11-1.92), Female sex (OR = 1.59, 95% CI = 1.26-2.03), and having Medicaid insurance (OR = 1.71, 95% CI = 1.37-2.14) were associated with increased utilization, while being under 18 was associated with lower utilization (<12: OR = 0.38, 95% CI = 0.26-0.56; 12-18: OR = 0.47, 95% CI = 0.35-0.63). These demographics were also associated with ED readmission within 90 days, while being under 18 was associated with a lower odds of readmission. CONCLUSIONS: Among patients with a history of suicidality, those who identify as Black, young adults, patients with Medicaid, and female patients were more likely to be frequent utilizers of the ED within the 2 years following their initial visit. This pattern may suggest inadequate health care access for these groups, and a need to develop better care coordination with an intersectional focus to facilitate utilization of other health services.

Common Data Element Collection in Underserved School Communities: Challenges and Recommendations.

OBJECTIVES: To provide recommendations for future common data element (CDE) development and collection that increases community partnership, harmonizes data interpretation, and continues to reduce barriers of mistrust between researchers and underserved communities. METHODS: We conducted a cross-sectional qualitative and quantitative evaluation of mandatory CDE collection among Rapid Acceleration of Diagnostics-Underserved Populations Return to School project teams with various priority populations and geographic locations in the United States to: (1) compare racial and ethnic representativeness of participants completing CDE questions relative to participants enrolled in project-level testing initiatives and (2) identify the amount of missing CDE data by CDE domain. Additionally, we conducted analyses stratified by aim-level variables characterizing CDE collection strategies. RESULTS: There were 15 study aims reported across the 13 participating Return to School projects, of which 7 (47%) were structured so that CDEs were fully uncoupled from the testing initiative, 4 (27%) were fully coupled, and 4 (27%) were partially coupled. In 9 (60%) study aims, participant incentives were provided in the form of monetary compensation. Most project teams modified CDE questions (8/13; 62%) to fit their population. Across all 13 projects, there was minimal variation in the racial and ethnic distribution of CDE survey participants from those who participated in testing; however, fully uncoupling CDE questions from testing increased the proportion of Black and Hispanic individuals participating in both initiatives. CONCLUSIONS: Collaboration with underrepresented populations from the early study design process may improve interest and participation in CDE collection efforts.

Building School-Academic Partnerships to Implement COVID-19 Testing in Underserved Populations.

OBJECTIVE: In April 2021, the US government made substantial investments in students' safe return to school by providing resources for school-based coronavirus disease 2019 (COVID-19) mitigation strategies, including COVID-19 diagnostic testing. However, testing uptake and access among vulnerable children and children with medical complexities remained unclear. METHODS: The Rapid Acceleration of Diagnostics Underserved Populations program was established by the National Institutes of Health to implement and evaluate COVID-19 testing programs in underserved populations. Researchers partnered with schools to implement COVID-19 testing programs. The authors of this study evaluated COVID-19 testing program implementation and enrollment and sought to determine key implementation strategies. A modified Nominal Group Technique was used to survey program leads to identify and rank testing strategies to provide a consensus of high-priority strategies for infectious disease testing in schools for vulnerable children and children with medical complexities. RESULTS: Among the 11 programs responding to the survey, 4 (36%) included prekindergarten and early care education, 8 (73%) worked with socioeconomically disadvantaged populations, and 4 focused on children with developmental disabilities. A total of 81 916 COVID-19 tests were performed. "Adapting testing strategies to meet the needs, preferences, and changing guidelines," "holding regular meetings with school leadership and staff," and "assessing and responding to community needs" were identified as key implementation strategies by program leads. CONCLUSIONS: School-academic partnerships helped provide COVID-19 testing in vulnerable children and children with medical complexities using approaches that met the needs of these populations. Additional work is needed to develop best practices for in-school infectious disease testing in all children.

Evaluation of the Risk Identification for Suicide and Enhanced Care Model in a Native American Community.

Importance: There are many prognostic models of suicide risk, but few have been prospectively evaluated, and none has been developed specifically for Native American populations. Objective: To prospectively validate a statistical risk model implemented in a community setting and evaluate whether use of this model was associated with improved reach of evidence-based care and reduced subsequent suicide-related behavior among high-risk individuals. Design, Setting, and Participants: This prognostic study, done in partnership with the White Mountain Apache Tribe, used data collected by the Apache Celebrating Life program for adults aged 25 years or older identified as at risk for suicide and/or self-harm from January 1, 2017, through August 31, 2022. Data were divided into 2 cohorts: (1) individuals and suicide-related events from the period prior to suicide risk alerts being active (February 29, 2020) and (2) individuals and events from the time after alerts were activated. Main Outcomes and Measures: Aim 1 focused on a prospective validation of the risk model in cohort 1. Aim 2 compared the odds of repeated suicide-related events and the reach of brief contact interventions among high-risk cases between cohort 2 and cohort 1. Results: Across both cohorts, a total of 400 individuals identified as at risk for suicide and/or self-harm (mean [SD] age, 36.5 [10.3] years; 210 females [52.5%]) had 781 suicide-related events. Cohort 1 included 256 individuals with index events prior to active notifications. Most index events (134 [52.5%]) were for binge substance use, followed by 101 (39.6%) for suicidal ideation, 28 (11.0%) for a suicide attempt, and 10 (3.9%) for self-injury. Among these individuals, 102 (39.5%) had subsequent suicidal behaviors. In cohort 1, the majority (220 [86.3%]) were classified as low risk, and 35 individuals (13.3%) were classified as high risk for suicidal attempt or death in the 12 months after their index event. Cohort 2 included 144 individuals with index events after notifications were activated. For aim 1, those classified as high risk had a greater odds of subsequent suicide-related events compared with those classified as low risk (odds ratio [OR], 3.47; 95% CI, 1.53-7.86; P = .003; area under the receiver operating characteristic curve, 0.65). For aim 2, which included 57 individuals classified as high risk across both cohorts, during the time when alerts were inactive, high-risk individuals were more likely to have subsequent suicidal behaviors compared with when alerts were active (OR, 9.14; 95% CI, 1.85-45.29; P = .007). Before the active alerts, only 1 of 35 (2.9%) individuals classified as high risk received a wellness check; after the alerts were activated, 11 of 22 (50.0%) individuals classified as high risk received 1 or more wellness checks. Conclusions and Relevance: This study showed that a statistical model and associated care system developed in partnership with the White Mountain Apache Tribe enhanced identification of individuals at high risk for suicide and was associated with a reduced risk for subsequent suicidal behaviors and increased reach of care.

A scoping review of implementation considerations for harm reduction vending machines.

BACKGROUND: Community-based harm reduction vending machines (HRVM) are not new to the field of public health; numerous countries have implemented them in response to the needs of people who use drugs over the last three decades. However, until recently, few existed in the United States. Given the rapidity with which communities are standing up harm reduction vending machines, there is a pressing need for a consolidated examination of implementation evidence. This scoping review summarizes existing literature using multiple implementation science frameworks. METHODS: The scoping review was conducted in five stages including (1) Identify the research question; (2) Identify relevant studies; (3) Select the publications based on inclusion/exclusion criteria; (4) Review and extract data; and, (5) Summarize results. PubMed, Embase, and Web of Science were searched and authors screened publications in English from any year. Data were extracted by applying implementation constructs from RE-AIM and the Consolidated Framework for Implementation Research (CFIR). Both frameworks provided a useful lens through which to develop knowledge about the facilitators and barriers to HRVM implementation. The review is reported according to PRISMA guidelines. RESULTS: After applying the full inclusion and exclusion criteria, including the intervention of interest ("vending machines") and population of interest ("people who use drugs"), a total of 22 studies were included in the scoping review. None of the studies reported on race, making it difficult to retroactively apply a racial equity lens. Among those articles that examined effectiveness, the outcomes were mixed between clear effectiveness and inconclusive results. Evidence emerged, however, to address all CFIR constructs, and positive outcomes were observed from HRVM's after-hour availability and increased program reach. RECOMMENDATIONS: HRVM implementation best practices include maximizing accessibility up to 24 h, 7 days a week, offering syringe disposal options, ensuring capability of data collection, and allowing for anonymity of use. Organizations that implement HRVM should establish strong feedback loops between them, their program participants, and the broader community upfront. Considerations for future research include rigorous study designs to evaluate effectiveness outcomes (e.g. reduced drug overdose deaths) and examination of HRVM reach among ethnic and racial communities.

Planning for implementation and sustainability of a community-based suicide surveillance system in a Native American community.

BACKGROUND: Native American youth, primarily living on reservations, suffer the highest burden of suicide of any racial group in the USA. Implementation and sustainability of culturally grounded, evidence-based interventions are needed to address suicide in Native American populations. For nearly 40 years, Montana has ranked at or near the top nationwide for suicide. Fort Peck Tribal leadership declared a state of emergency in 2010 after six suicides and 20 attempts that occurred over a 5-month period. METHODS: We used a community-based participatory research approach for adapting the Celebrating Life (CL) program with a specific focus on long-term sustainability, which has demonstrated efficacy in addressing suicide with the White Mountain Apache. The aims were to (1) adapt the CL program intake forms through roundtable discussions, (2) conduct asset and resource mapping to identify community and cultural resources to leverage for the CL program within the Fort Peck context, and (3) develop a sustainability plan for CL in Fort Peck through qualitative approaches informed by the Program Sustainability Assessment Tool. RESULTS: Roundtable discussions resulted in adapted intake forms that capture variables relevant to the Fort Peck context. Asset mapping identified 13 community assets and 10 cultural resources to incorporate within the CL implementation process. Focus group discussions yielded four key themes that were incorporated into a plan for sustainability: (1) strategic partnerships, (2) long-term funding, (3) communication planning, and (4) workforce planning and engagement. CONCLUSIONS: This paper outlines an avenue for using culturally adapted tools to design an implementation system driven by community and cultural assets within tribal communities and for integrating program planning for sustainability early in the implementation process.

Understanding opioid use within a Southwestern American Indian Reservation Community: A qualitative study.

PURPOSE: Morbidity and mortality due to nonprescription use of opioids has been well documented following the significant increase in the availability of prescription opioids in the early 2000s. The aim of this paper is to explore community beliefs about correlates of opioid risk, protective factors, and behavioral functions of opioid misuse among American Indian youth and young adults living on or near a reservation. METHODS: Qualitative in-depth interviews were conducted with N = 18 youth and young adults who were enrolled in a parent research trial focused on American Indian youth suicide prevention. Participants were eligible if they endorsed the use of opioids themselves or by close friends or family members at any point during their trial participation. FINDINGS: Major themes discussed include: (1) description of opioid use and those who use opioids; (2) acquisition; (3) initiation; (4) motivation to continue using; (5) consequences; and (6) possibilities for intervention. Family played an important role in the initiation of use, but was also highlighted as an important factor in treatment and recovery. A need for upstream prevention methods, including increased employment and after-school activities, was described. CONCLUSIONS: The insights gained through this work could help to inform treatment and prevention programs in the community. This work is timely due to the pressing urgency of the opioid epidemic nationally, and community capacity to address opioid use locally.

Expert-generated standard practice elements for evidence-based home visiting programs using a Delphi process.

BACKGROUND: States, territories, non-profits, and tribes are eligible to obtain federal funding to implement federally endorsed evidence-based home visiting programs. This represents a massive success in translational science, with $400 million a year allocated to these implementation efforts. This legislation also requires that 3% of this annual funding be allocated to tribal entities implementing home visiting in their communities. However, implementing stakeholders face challenges with selecting which program is best for their desired outcomes and context. Moreover, recent reviews have indicated that when implemented in practice and delivered at scale, many evidence-based home visiting programs fail to replicate the retention rates and effects achieved during clinical trials. To inform program implementers and better identify the active ingredients in home visiting programs that drive significant impacts, we aimed to develop an expert derived consensus taxonomy on the elements used in home visiting practice that are essential to priority outcome domains. METHODS: We convened a panel of 16 experts representing researchers, model representatives, and program implementers using a Delphi approach. We first elicited standard practice elements (SPEs) using open-ended inquiry, then compared these elements to behavior change techniques (BCTs) given their general importance in the field of home visiting; and finally rated their importance to 10 outcome domains. RESULTS: Our process identified 48 SPEs derived from the panel, with 83 additional BCTs added based on the literature. Six SPEs, mostly related to home visitor characteristics and skills, were rated essential across all outcome domains. Fifty-three of the 83 BCTs were rated unnecessary across all outcome domains. CONCLUSIONS: This work represents the first step in a consensus-grounded taxonomy of techniques and strategies necessary for home visiting programs and provides a framework for future hypothesis testing and replication studies.

Towards precision home visiting: results at six months postpartum from a randomized pilot implementation trial to assess the feasibility of a precision approach to Family Spirit.

BACKGROUND: Shared implementation challenges at scale in early childhood home visiting have led researchers to explore precision home visiting as a promising service delivery mechanism to better address families' unique needs and build greater program efficiencies. This randomized controlled pilot study aimed to assess the acceptability of a precision approach to one home visiting model, Family Spirit® and explore potential differences between Precision Family Spirit (PFS) and Standard Family Spirit (Standard FS) on participant-home visitor relationship and maternal outcomes. METHODS: Participants (N = 60) were at least 14 years old, pregnant or within 2 months postpartum, and enrolled in Family Spirit. Four sites in Michigan were randomized 1:1 to deliver PFS (up to 17 core lessons plus up to 13 additional lessons as needed) or Standard FS (home visiting services as usual). Primary (program acceptability, participant satisfaction, home visitor-participant relationship quality, retention, adherence) and secondary (knowledge, quality of life, difficulty with parenting problems, substance use, depression, stress) outcomes at 6 months postpartum are presented. PFS participants also self-reported on quality of life, difficulty with parenting problems, stress, substance use, and concerns with sexual and reproductive health and self and child's nutrition status at each home visit. This informed which lessons they should receive. RESULTS: Mothers in both groups reported positive program acceptability, satisfaction, and home visitor-participant relationships at 6 months postpartum. However, open-ended feedback from Standard FS participants indicates that some lesson content may not be applicable to all participants. At 6 months, retention was 82.3% for PFS and 66.7% for Standard FS, and adherence was 30.1% for PFS and 20.6% for Standard FS. CONCLUSIONS: Preliminary findings indicate that precision home visiting may be acceptable and feasible. A definitive trial is needed to build on this pilot data, assess outcomes for mothers and children participating in a precision approach to home visiting as compared to standard home visiting, and ready this approach for scale. TRIAL REGISTRATION: ClinicalTrials.gov NCT03975530 (first posted on 05/06/2019).

Home visitor perspectives on implementing a precision approach to home visiting in communities serving Native American families.

Family Spirit (FS) is a federally endorsed evidence-based home visiting programs serving as a key prevention strategy for expectant families and families with young children. Like other home-visiting programs, it shares client challenges in retention and engagement during implementation. We assessed (1) the feasibility and acceptability of implementing a precision approach to FS; and (2) differences in approaches to FS delivery. Home visitors, serving primarily Native American families, that delivered a standard (N = 6) or a precision approach (N = 6) to FS across four study sites each participated in up to four virtual focus group discussions (FGDs) (N = 16). Facilitators and barriers to implementation were identified across the curriculum approach, relational and contextual levels. Facilitators: Relevant and culturally sensitive lessons, lesson structure, client-home visitor relationship, client buy-in, home visitor autonomy, leadership support, flexible funding, and training. Barriers: Irrelevant lessons, substance use content, missing topics, families experiencing crises, client and home visitor availability, client feedback, nonsupportive leadership, inadequate funding, and organizational policies and practices. The precision approach offers (1) tailoring of lessons that supports relevance of content to clients; and (2) a target timeframe that supports flexibility in lesson delivery. This model structure may improve client participation and retention.

Espíritu de Familia (FS) es un programa de visitas a casa con base en la evidencia y respaldado federalmente, el cual sirve como una estrategia clave de prevención para familias con niños pequeños que esperan otro niño. Tal como otros programas de visitas a casa, éste comparte los retos de los participantes en cuanto a retención y participación activa durante la implementación. Evaluamos 1) la factibilidad y accesibilidad de implementar un acercamiento de precisión a FS; y 2) las diferencias en cuanto al acercamiento del ofrecimiento de FS. Los visitadores a casa, quienes primariamente les sirven a familia nativo-americanas, y que ofrecieron un acercamiento estándar (N = 6) o uno de precisión (N = 6) a FS a través de 4 lugares de estudio, cada uno participó en un máximo de 4 discusiones virtuales de grupos de enfoque (N = 16). Los aspectos que facilitaron y las barreras a la implementación se identificaron a lo largo de los niveles de acercamiento, relacionales y contextuales del currículo. Aspectos que facilitaron: lecciones relevantes y culturalmente sensibles, estructura de lecciones, la relación entre el participante-casa y el visitador, la aceptación por parte del participante, la autonomía del visitador a casa, el apoyo de liderazgo, la flexibilidad de los fondos, así como el entrenamiento. Barreras: lecciones irrelevantes, contenido sobre uso de sustancias, temas que no se incluyeron, las familias que experimentaban una crisis, la disponibilidad del participante y del visitador, información aportada por el participante, falta de apoyo del liderazgo, fondos inadecuados, así como las políticas y prácticas organizacionales. El acercamiento de precisión ofrece 1) moldear las lecciones que apoyan la relevancia del contenido a los participantes; y 2) un definido marco de tiempo que apoya la flexibilidad del ofrecimiento de las lecciones. Esta estructura de modelo pudiera mejorar la participación y retención de participantes.

Le programme Family Spirit (FS, soit Esprit de Famille) est une programme américain, basé sur des données probantes, avalisé par le gouvernement américain, de visite à domicile, servant de stratégie de prévention clé pour les familles attendant un enfant ou les familles avec de jeunes enfants. Comme d'autres programmes de visite à domicile, ce programme partage des difficultés dans la rétention et l'engagement des clients durant la mise en oeuvre. Nous avons évalué 1) la fiabilité et l'acceptabilité de la mise en œuvre d'une approche de précision du FS; et 2) des différences dans les approches de l'application du FS. Les visiteurs à domicile, servant principalement des familles amérindiennes américaines, qui ont présenté une approche standard (N = 6) ou une approche de précision (N = 6) du FS et au travers de 4 sites d'étude chacun ont participé à jusqu'à 4 discussions de groupe d'étude virtuels (n = 16). Les aspects facilitateurs et les barrières à la mise en place ont été identifiés au travers de l'approche du curriculum, des niveaux relationnels et contextuels. Aspects de facilitation: leçons pertinentes et culturellement sensibles, structure de la leçon, relation client-visiteur à domicile, adhésion du client, autonomie du visiteur à domicile, soutient des dirigeants, budget flexible, formation. Barrières: leçons n'étant pas pertinentes, contenu d'usage de substance, sujets qui manquent, familles faisant l'expérience de crises, disponibilité du client et du visiteur à domicile, retour du client, dirigeants qui n'offrent aucun soutien, budget inadéquat, et politiques et pratiques organisationnelles. L'approche de précision offre 1) une adaptation sur mesure des leçons qui soutient la pertinence du contenu pour les clients; et 2) un délai ciblé qui soutient la flexibilité de l'enseignement. Cette structure de modèle peut améliorer la participation et la rétention.