Fidelity of implementation of an evidence-based HIV prevention program among Bahamian sixth grade students.

The Bahamian Ministry of Education has elected to implement at a national level in all Bahamian government grade six classes an evidence-based HIV prevention intervention [Focus on Youth in the Caribbean (FOYC)]. This study explores fidelity of implementation of the intervention, factors that may influence implementation fidelity, and the impact of variations in the implementation fidelity on student outcomes. Data were collected in the first wave of national implementation in 2011, involving 35 government primary schools and 110 teachers and 2,811 students. Structural equation modeling was performed to examine the relationships among factors which facilitated or impeded teachers' implementation of FOYC. Results indicate that teachers taught 16.3 out of 30 core activities, 24.9 out of 46 total activities, and 4.4 out of 8 sessions on average. The strongest predictor of implementation fidelity was teacher comfort level with the FOYC curriculum. Teachers who did not perceive the FOYC intervention to be important for their students or who had attended only part of a FOYC training workshop were more likely to change the curriculum. Increased duration of experience as a teacher (>10 years) was negatively associated with fidelity of implementation. Teacher's perception of the importance of the FOYC intervention and implementation fidelity had direct positive effects on students' HIV/AIDS knowledge, reproductive health skills, protective intentions, and self-efficacy. Youth did not appear to benefit from FOYC if two or fewer sessions were delivered. We concluded that an evidence-based HIV prevention intervention can be implemented at a national level. Prior training of teachers in the intervention curriculum, teacher perception of the importance of the intervention, and fewer years as a teacher are associated with implementation fidelity. Implementation fidelity is associated with improved student outcomes.

Sustained institutional effects of an evidence-based HIV prevention intervention.

Limited data are available as to what happens in institutions involved in behavioral intervention trials after the trial has ended. Specifically, do the trainers continue to administer the behavioral intervention that had been the focus of the trial? To address this question, we examined data in grade six schools before a year-long behavioral intervention had been delivered in some schools (and a year-long control condition in others) and data obtained again 6 and 7 years later in the same two sets of schools. Data were derived from the baseline surveys of two interventions: (1) national implementation of the evidence-based Focus on Youth in the Caribbean (FOYC) intervention in 2011; and (2) the randomized, controlled trial of the FOYC intervention in 2004/2005. Cross-sectional, longitudinal comparisons and random coefficient regression analysis were conducted to evaluate long-term intervention effects. Results indicate that grade six students in 2011 from schools in which the FOYC intervention had been implemented in 2004/2005 had a higher level of HIV/AIDS knowledge, increased reproductive health skills, increased self-efficacy regarding their ability to prevent HIV infection, and greater intention to use protection if they were to have sex compared to their counterparts from schools where no such training took place. We concluded that new cohorts of students benefited from the extensive training and/or experience in teaching the FOYC curriculum received by teachers, guidance counselors and administrators in schools which had delivered the FOYC intervention as part of a randomized trial several years earlier. The findings suggest that teachers who previously were trained to deliver the FOYC intervention may continue to teach at least some portions of the curriculum to subsequent classes of students attending these schools.

Preparing for national implementation of an evidence-based, effective HIV prevention program among bahamian sixth-grade students.

Using data from the preparatory phase prior to national implementation of an effective HIV prevention program (Focus on Youth in the Caribbean; FOYC) in all Bahamian government sixth-grade classes, we describe (1) actual FOYC implementation, (2) factors that influenced implementation, and (3) the relationship of implementation with intervention outcome. Six elementary schools (with 17 grade six classrooms) were selected to participate in the preparatory phase. The 17 teachers were invited to attend a training workshop, coordinate administration of questionnaires to the students, teach the 10 sessions of FOYC and complete self-assessment checklists. A total of 395 students submitted baseline and 311 students submitted year-end questionnaires. Thirteen teachers initiated FOYC; five completed all 10 sessions. Implementation of FOYC was not related to teacher FOYC workshop experience but did cluster by school. There were significant positive correlations between improved student knowledge of HIV/AIDS, protective health skills, perceived parental monitoring and reduced risk behaviours with the number of FOYC sessions delivered. Implementation was impeded by logistics issues, structural issues with the measures, and comfort-level issues, most of which can be addressed for national implementation. Degree of FOYC implementation is correlated with positive student outcomes.

National Implementation of an Evidence-Based HIV Prevention and Reproductive Health Program for Bahamian Youth.

A wide range of behavioral prevention interventions have been demonstrated through longitudinal, randomized controlled trials to reduce sexual risk behaviors. Many of these interventions have been made available at little cost for implementation on a public health scale. However, efforts to utilize such programs typically have been met with a range of problems to be addressed, leading to the recognition that new processes must be identified and integrated into the emerging field of implementation science. A randomized, controlled trial conducted among Bahamian grade six students attending fifteen elementary schools found the sexual risk-reduction intervention "Focus on Youth in the Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT)" to be effective through three years of follow-up. Based on these results, the Bahamian Ministry of Education decided to implement FOYC-CImPACT throughout all government grade six classes in The Bahamas. This manuscript describes the considerations, approaches, and actions taken regarding national implementation of this evidence-based intervention. The implementation process included active data-gathering, observation and feedback components to inform subsequent intervention phases. This manuscript reviewed the success and challenges to date within this framework and described changes made to enable next stages of the national implementation effort.

Crisis and crisis behaviour

This research project was organized around the following two premises: (1) That the present conceptual models utilized for defining and assessing 'crisis' and 'crisis behaviour' were generally too vague. Each model focussed on predominantly one aspect of the crisis experience at the expense of comprising a comprehensive, holistic frame of reference. (2) That limited staff and large case loads functioned to limit the amount of time that human service personnel could spend with clients in crisis. Hence, it was deemed necessary for a particular understanding of 'crisis' that would facilitate the implementation of management schemes that would effect the greatest degree of change in as many areas of the client's life within the shortest period of time. The investigation was organized in three major parts. Part I presented an overview of the literature, critiquing the traditional approaches to the definition of crisis and tracing the evolution of the concept from its inception as a description of grief reaction, to the diversified concept that it is today. It introduced an alternative conceptual model that presented crisis as a 'process'. It was hypothesised that the process began with the precipitating factors and progressed through six stages. The stages reflected a progressive fragmentation of the components of the individual's identity. Part II focussed on hypotheses suggesting that the ethnic personality of the individual influenced his response-nature and pattern. Ethnic personality was defined as having two elements: (1) A socialised predisposition to act in ways reflecting prescribed behaviour patterns. (2) An innate predisposition to act in ways that express the composites of one's human nature. Human nature was defined as being a mental-spiritual-physical entity. The dominant component within this triad was deemed to be the spiritual element. Part III of the project presents the results of an exploratory study conducted to assess the feasibility of the seven hypotheses that were formulated at the end of Part II of the theoretical overview. Using the clinical method, one and a half hour long interviews were conducted with forty adolescent girls between the ages of twelve and fifteen years old. Results indicated that the crisis could be conceptualized as a six stage process. Whether or not an individual proceeded through these stages depended on the nature of the hazardous event. Subjects did manifest concern about the fragmentation of their social status and identity. They also experienced predominantly hostile feelings. Religious/affective responses reflective of the ethnic personality of the group were not apparent until the last stages of the crisis experience. Another component found to be influencing behaviour, was 'sense of mastery'. Concluding remarks highlighted possible management schemes that might effect a more effective short-term approach to treating patients in crisis (AU)