A mixed methods investigation of implementation determinants for a school-based universal prevention intervention

Abstract

Background: Effective implementation of evidence-based prevention interventions in schools is vital to reducing the burden of drug use and its consequences. Universal prevention interventions often fail to achieve desired public health outcomes due to poor implementation. One central reason for suboptimal implementation is the limited fit between the intervention and the setting. Research is needed to increase our understanding of how intervention characteristics and context influence intervention implementation in schools to design implementation strategies that will address barriers and improve public health impact.

Methods: Using a convergent mixed methods design we examined qualitative and quantitative data on implementation determinants for an evidence-based health curriculum, the Michigan Model for Health^TM (MMH) from the perspective of health teachers delivering the curriculum in high schools across the state. We examined data strands independently and integrated them by investigating data alignment, expansion, and divergence.

Results: We identified three mixed methods domains: (1) Acceptability, (2) intervention-context fit, and (3) adaptability. We found alignment across data strands as teachers reporting low acceptability also reported low fidelity. The fit between student needs and the curriculum predicted fidelity (expansion). Teachers mentioned instances of poor intervention-context fit (discordance), including when meeting the needs of trauma-exposed youth and keeping updated on youth drug use trends. Teachers reported high adaptability (concordance) but also instances when adaptation was challenging (discordance).

Conclusions: This investigation advances implementation research by deepening our understanding of implementation determinants for an evidence-based universal prevention intervention in schools. This will support designing effective implementation strategies to address barriers and advance the public health impact of interventions that address important risk and protective factors for all youth.

Plain language summary: (1) What is Already Known About the Topic? While many evidence-based interventions (EBIs) exist to address key health issues among youth including substance use and mental health, few of these interventions are effectively implemented in community settings, such as schools. Notable multilevel barriers exist to implement universal prevention in schools. Researchers identify that misalignment between the intervention and the context is a key reason why many implementation efforts do not achieve desired outcomes. (2) What Does This Paper Add? This paper combines the strengths of qualitative and quantitative research methods to identify and understand challenges to intervention-context fit for a comprehensive health curriculum, the Michigan Model for Health^TM (MMH) which is widely adopted throughout Michigan, from the perspective of end users. This paper also utilizes the consolidated framework for implementation research and implementation outcomes framework to guide our understanding of implementing complex interventions and key barriers to implementation in schools. This research provides a foundation to design effective strategies that will balance curriculum fidelity and adaptation to achieve public health objectives. (3) What are the Implications for Practice, Research, or Policy? We need implementation strategies that guide flexibility and fidelity in EBI delivery in schools. While overall teachers felt the curriculum was adaptable and met student needs, they also mentioned specific instances when they would benefit from additional implementation support, such as making adaptations to meet the needs of trauma-exposed youth and keeping up-to-date with emerging drugs. Implementation strategies designed to address these challenges can improve fidelity and ultimately student well-being.

Keywords: adolescence; implementation science; mixed methods; prevention; school health; substance use.

Figure 1.

Factors that influence fidelity and adaptation, adapted from Allen et al., 2018. ^aAcceptability of the Michigan Model for Health^TM (MMH) intervention from teachers’ perspectives.

Figure 2.

Convergent mixed methods design.

Figure 3.

Example of how the current study results can inform selecting suitable implementation strategies to address key implementation barriers, using the first components of the Implementation Research Logic Model adapted from Smith et al. (2020) and using the Consolidated Framework for Implementation Research (CFIR; Damschroder et. al., 2009)-Expert Recommendations for Implementing Change (ERIC; Powell et al., 2015) implementation strategy matching tool.