Influence of provider openness and leadership behaviors on adherence to motivational interviewing training implementation strategies: Considerations for evidence-based practice delivery.

Background: Adherence to intervention training implementation strategies is at the foundation of fidelity; however, few studies have linked training adherence to trainee attitudes and leadership behaviors to identify what practically matters for the adoption and dissemination of evidence-based practices. Through the conduct of this hybrid type 3 effectiveness-implementation cluster randomized controlled trial, we collected Exploration, Preparation, Implementation, and Sustainment (EPIS) data and merged it with tailored motivational interviewing training adherence data, to elucidate the relationship between provider attitudes toward evidence-based practices, leadership behaviors, and training implementation strategy (e.g., workshop attendance and participation in one-on-one coaching) adherence. Method: Our sample included data from providers who completed baseline (pre-intervention) surveys that captured inner and outer contexts affecting implementation and participated in tailored motivational interviewing training, producing a dataset that included training implementation strategies adherence and barriers and facilitators to implementation (N = 77). Leadership was assessed by two scales: the director leadership scale and implementation leadership scale. Attitudes were measured with the evidence-based practice attitude scale (EBPAS-50). Adherence to training implementation strategies was modeled as a continuous outcome with a Gaussian distribution. Analyses were conducted in SPSS. Results: Of the nine general attitudes toward evidence-based practice, openness was associated with training adherence (estimate [EST] = 0.096, p < .001; 95% CI = [0.040, 0.151]). Provider general (EST = 0.054, 95% CI = [0.007, 0.102]) and motivational interviewing-specific (EST = 0.044, 95% CI = [0.002, 0.086]) leadership behaviors were positively associated with training adherence (p < .05). Of the four motivational interviewing-specific leadership domains, knowledge and perseverant were associated with training adherence (p < .05). As these leadership behaviors increased, knowledge (EST = 0.042, 95% CI = [0.001, 0.083]) and perseverant (EST = 0.039, 95% CI = [0.004, 0.075]), so did provider adherence to training implementation strategies. Conclusions: As implementation science places more emphasis on assessing readiness prior to delivering evidence-based practices by evaluating organizational climate, funding streams, and change culture, consideration should also be given to metrics of leadership. A potential mechanism to overcome resistance is via the implementation of training strategies focused on addressing leadership prior to conducting training for the evidence-based practice of interest.

Researchers and practitioners, who aim to improve the uptake of evidence-based practices, continue to seek ways in which to improve provider participation in training implementation strategies. The persistent challenge in addressing provider disengagement, while linking this disinterest to poor patient outcomes, has been ascertaining how to quantify relevant delivery considerations, for example, provider attitudes and leadership behaviors that may influence commitment to learning or apathy to behavior change, concurrently with training adherence. Through the conduct of this study, we collected both types of data: (1) provider attitudes and leadership behaviors and (2) training adherence outcomes. We found that provider openness, general leadership behaviors, and motivational interviewing-specific leadership behaviors were associated with adherence to training implementation strategies. As more emphasis is placed on assessing clinic readiness prior to adopting new evidence-based practices, a discussion on including metrics of provider attitudes to evidence-based practice, innovation, and the specific intervention is warranted, alongside consideration for how implementation training strategies focused on addressing leadership can bolster change-supportive behaviors prior to delivery of innovations.

The relative value of Pre-Implementation stages for successful implementation of evidence-informed programs.

BACKGROUND: Most implementations fail before the corresponding services are ever delivered. Measuring implementation process fidelity may reveal when and why these attempts fail. This knowledge is necessary to support the achievement of positive implementation milestones, such as delivering services to clients (program start-up) and competency in treatment delivery. The present study evaluates the extent to which implementation process fidelity at different implementation stages predicts achievement of those milestones. METHODS: Implementation process fidelity data-as measured by the Stages of Implementation Completion (SIC)-from 1287 implementing sites across 27 evidence-informed programs were examined in mixed effects regression models with sites nested within programs. Implementation process fidelity, as measured by the proportion of implementation activities completed during the three stages of the SIC Pre-Implementation phase and overall Pre-Implementation (Phase 1) and Implementation (Phase 2) proportion scores, was assessed as a predictor of sites achieving program start-up (i.e., delivering services) and competency in program delivery. RESULTS: The predicted probability of start-up across all sites was low at 35% (95% CI [33%, 38%]). When considering the evidence-informed program being implemented, that probability was nearly twice as high (64%; 95% CI [42%, 82%]), and 57% of the total variance in program start-up was attributable to the program. Implementation process fidelity was positively and significantly associated with achievement of program start-up and competency. The magnitude of this relationship varied significantly across programs for Pre-Implementation Stage 1 (i.e., Engagement) only. Compared to other stages, completing more Pre-Implementation Stage 3 (Readiness Planning) activities resulted in the most rapid gains in probability of achieving program start-up. The predicted probability of achieving competency was very low unless sites had high scores in both Pre-Implementation and Implementation phases. CONCLUSIONS: Strong implementation process fidelity-as measured by SIC Pre-Implementation and Implementation phase proportion scores-was associated with sites' achievement of program start-up and competency in program delivery, with early implementation process fidelity being especially potent. These findings highlight the importance of a rigorous Pre-Implementation process.

Relating Facial Trustworthiness to Antisocial Behavior in Adolescent and Adult Men.

Here, we investigate how facial trustworthiness-a socially influential appearance variable-interrelates with antisocial behavior across adolescence and middle adulthood. Specifically, adolescents who look untrustworthy may be treated with suspicion, leading to antisocial behavior through expectancy effects. Alternatively, early antisocial behaviors may promote an untrustworthy appearance over time (Dorian Gray effect). We tested these expectancy and Dorian Gray effects in a longitudinal study that followed 206 at-risk boys (90% White) from ages 13-38 years. Parallel process piecewise growth models indicated that facial trustworthiness (assessed from photographs taken prospectively) declined during adolescence and then stabilized in adulthood. Consistent with expectancy effects, initial levels of facial trustworthiness were positively related to increases in antisocial behavior during adolescence and also during adulthood. Additionally, higher initial levels of antisocial behavior predicted relative decreases in facial trustworthiness across adolescence. Adolescent boys' facial appearance may therefore both encourage and reflect antisocial behavior over time.

Improving the feasibility of fidelity measurement for community-based quality assurance: Partial- versus full-session observations of supervisor adherence and competence.

Background: Clinical supervision is a common quality assurance method for supporting the implementation and sustainment of evidence-based interventions (EBIs) in community mental health settings. However, assessing and supporting supervisor fidelity requires efficient and effective measurement methods. This study evaluated two observational coding approaches that are potentially more efficient than coding full sessions: a randomly selected 15-min segment and the first case discussion of the session. Method: Data were leveraged from a randomized trial of an Audit and Feedback (A&F) intervention for supervisor Adherence and Competence. Supervisors (N = 57) recorded and uploaded weekly group supervision sessions for 7 months, with one session observationally coded each month (N = 374). Of the coded sessions, one was randomly selected for each supervisor, and a random 15-min segment was coded. Additionally, the first case discussion was coded for the full sample of sessions. Results: Across all models (and controlling for the proportion of the session covered by the partial observation), Adherence and Competence scores from partial observations were positively and significantly associated with scores from full sessions. In all cases, partial observations were most accurate when the level of Adherence and Competence was moderate. At lower levels, partial observations were underestimates, and at higher levels, they were overestimates. Conclusions: The results suggest that efficient observational measurement can be achieved while retaining a general level of measurement effectiveness. Practically, first-case discussions are easier to implement, whereas 15-min segments have fewer potential threats to validity. Evaluation of resource requirements is needed, along with determining whether A&F effects are retained if feedback is based on partial observations. Nevertheless, more efficient observational coding could increase the feasibility of routine fidelity monitoring and quality assurance strategies, including A&F, which ultimately could support the implementation and sustainment of effective supervision practices and EBIs in community practice settings.Plain Language Summary: When delivering evidence-based mental health interventions in community-based practice settings, a common quality assurance method is clinical supervision. To support supervisors, assessment methods are needed, and those methods need to be both efficient and effective. Ideally, supervision sessions would be recorded, and trained coders would rate the supervisor's use of specific strategies. In most settings, though, this requires too many resources. The present study evaluated a more efficient approach. The data came from an existing randomized trial of an Audit and Feedback intervention for enhancing supervisor Adherence and Competence. This included 57 supervisors and 374 sessions across seven months of monitoring. Instead of rating full supervision sessions, a more efficient approach was to have coders rate partial sessions. Two types of partial observations were considered: a randomly selected 15-minute segment of the session and the first case discussion of the session. The aim was to see if partial observations and full observations led to similar conclusions about Adherence and Competence. In all cases, they did. The scores were most similar for sessions with moderate levels of Adherence and Competence. If Adherence and Competence were low, partial observations were underestimates, but if they were high, partial observations were overestimates. Observing partial sessions is more efficient, but in terms of accuracy, the benefits and limitations should be evaluated in light of how the scores will be used. Additionally, future research should consider whether Audit and Feedback interventions have the same effect if feedback is based on observations of partial sessions.

Enhancing gender and ethnic representativeness of NCHA-II data with survey weights: The examples of substance use prevalence and state marijuana legalization.

OBJECTIVE: We evaluated how applying post-stratification sampling weights to National College Health Assessment II (NCHA-II) data affects estimates of substance use prevalence and tests of medical and recreational marijuana legalization (MML and RML) effects. Participants/Methods: We constructed weights for Fall 2015 and Spring 2016 surveys (n = 90,503) using population information on U.S. undergraduates' gender and race/ethnicity and three institutional characteristics (region, city population, public/private). We estimated substance use prevalence (e.g., e-cigarettes, prescription opioid misuse) and compared 30-day marijuana use rates in states with RML, MML, or neither policy. Results: When unweighted versus weighted data were used, prevalence estimates did not differ appreciably; conclusions from logistic regressions were similar (weighted 30-day marijuana use rates among undergraduates in RML, MML, and non-ML states were 30.0%, 20.3%, and 16.3%, respectively) but effect sizes differed. Conclusions: The value of using weighted NCHA-II data depends on the analysis and the precision required for the research questions.

Trends in college students' alcohol, nicotine, prescription opioid and other drug use after recreational marijuana legalization: 2008-2018.

BACKGROUND: Young adult college students may be particularly sensitive to recreational marijuana legalization (RML). Although evidence indicates the prevalence of marijuana use among college students increased after states instituted RML, there have been few national studies investigating changes in college students' other substance use post-RML. METHOD: The cross-sectional National College Health Assessment-II survey was administered twice yearly from 2008 to 2018 at four-year colleges and universities. Participants were 18-26 year old undergraduates attending college in states that did (n = 243,160) or did not (n = 624,342) implement RML by 2018. Outcome variables were self-reported nicotine use, binge drinking, illicit drug use, and misuse of prescription stimulants, sedatives, and opioids. Other variables included individual and contextual covariates, and institution-reported institutional and community covariates. Publicly available information was used to code state RML status at each survey administration. RESULTS: Accounting for state differences and time trends, RML was associated with decreased binge drinking prevalence among college students age 21 and older [OR (95% CI) = 0.91 (0.87 - 0.95), p < .0001] and increased sedative misuse among minors [OR (95% CI) = 1.20 (1.09 - 1.32), p = .0003]. RML did not disrupt secular trends in other substance use. CONCLUSIONS: In the context of related research showing national increases in college students' marijuana use prevalence and relative increases following state RML, we observed decreases in binge drinking and increases in sedative use that both depended on age. Findings support some specificity in RML-related changes in substance use trends and the importance of individual factors.