A large-scale initiative to disseminate an evidence-based drug abuse prevention program in Italy: Lessons learned for practitioners and researchers

Across developed countries, experimentation with alcohol, tobacco, and other drugs often begins in the early adolescent years. Several evidence-based programs have been developed to prevent adolescent substance use. Many of the most rigorously tested and empirically supported prevention programs were initially developed and tested in the United States. Increasingly, these interventions are being adopted for use in Europe and throughout the world. This paper reports on a large-scale comprehensive initiative designed to select, adapt, implement, and sustain an evidence-based drug abuse prevention program in Italy. As part of a large-scale regionally funded collaboration in the Lombardy region of Italy, we report on processes through which a team of stakeholders selected, translated and culturally adapted, planned, implemented and evaluated the Life Skills Training (LST) school-based drug abuse prevention program, an evidence-based intervention developed in the United States. We discuss several challenges and lessons learned and implications for prevention practitioners and researchers attempting to undertake similar international dissemination projects. We review several published conceptual models designed to promote the replication and widespread dissemination of effective programs, and discuss their strengths and limitations in the context of planning and implementing a complex, large-scale real-world dissemination effort.     

“Compassion,pleasantry, and hope”: A process evaluation of a volunteer-based nonprofit

As funders continue to emphasize the importance of documented results, nonprofit organizations must work to complete program evaluations that are both valuable and feasible. The purpose of this paper is to document a practical process evaluation of a southeastern nonprofit, a local Meals on Wheels. Using a mixed methods approach, we sought to answer four evaluation questions: (1) What are the essential program components, as identified by key stakeholders; (2) To what extent are volunteers implementing the identified essential components as intended; (3) What is the level of volunteer satisfaction with the program; and (4) What suggestions do stakeholders have for improving the program? Our findings indicate that most aspects of the program were implemented as intended, but inconsistencies occurred when volunteers were unsure of their assigned duties. In addition, volunteers had high levels of satisfaction and specific suggestions for improvement. From these results, we developed a conceptual model of factors contributing to quality of implementation and volunteer satisfaction that may be generalizable to other volunteer-based nonprofits. Specifically, we identified three factors that helped to facilitate satisfaction and performance: leadership, social contact, and fulfillment. Finally, this process evaluation demonstrates the feasibility of developing and implementing evaluation tools in similar organizations.     

Agent-based modeling as a tool for program design and evaluation

Recently, systems thinking and systems science approaches have gained popularity in the field of evaluation; however, there has been relatively little exploration of how evaluators could use quantitative tools to assist in the implementation of systems approaches therein. The purpose of this paper is to explore potential uses of one such quantitative tool, agent-based modeling, in evaluation practice. To this end, we define agent-based modeling and offer potential uses for it in typical evaluation activities, including: engaging stakeholders, selecting an intervention, modeling program theory, setting performance targets, and interpreting evaluation results. We provide demonstrative examples from published agent-based modeling efforts both inside and outside the field of evaluation for each of the evaluative activities discussed. We further describe potential pitfalls of this tool and offer cautions for evaluators who may chose to implement it in their practice. Finally, the article concludes with a discussion of the future of agent-based modeling in evaluation practice and a call for more formal exploration of this tool as well as other approaches to simulation modeling in the field.     

A formative evaluation of the recovery public works programme in Blantyre City,Malawi

Public works programmes (PWPs) are popular social protection instruments in the context of chronic poverty but very little has been published in the way of implementation and outcomes of these programmes. This paper presents a formative process and outcome evaluation of the recovery PWP in Blantyre City, Malawi. The evaluation used longitudinal household survey data of PWP beneficiaries, programme records and interview responses from programme staff and community leaders. Largely, the process evaluation findings showed an agreement between actual and planned activities. The outcome evaluation found indications that the PWP community assets offered some potential benefits to the communities, and that PWP wages allowed the beneficiaries to purchase some food. This however, did not translate into more meals per day, nor did the earnings prevent the decline in household assets as expected. Given a plausible PWP theory and high implementation fidelity, the PWP wage rate or number of days was either just enough to smooth participant income, or insufficient altogether, to enable achievement of more distal outcomes.     

Who performs better under time pressure? Results from a field experiment

We investigate whether and how time pressure affects performance. We conducted a field experiment in which students from an Italian University are proposed to choose between two exam schemes: a standard scheme without time pressure and an alternative scheme consisting of two written intermediate tests, one of which to be taken under time pressure. Students deciding to sustain the alternative exam are randomly assigned to a “time pressure” and a “no time pressure” group. Students performing under time pressure at the first test perform in absence of time pressure at the second test and vice versa. We find that being exposed to time pressure exerts a negative and statistically significant impact on students’ performance. The effect is driven by a strong negative impact on females’ performance, while there is no statistically significant effect on males. Both the quantity and quality of females’ work is hampered by time pressure. Using data on students’ expectations, we also find that the effect produced by time pressure on performance was correctly perceived by students. Female students expect a lower grade when working under time pressure, while males do not. These findings contribute to explain why women tend to shy away from jobs and careers involving time pressure.     

The Perspectives of Young Men and Their Teenage Partners on Maternity and Health Services During Pregnancy and Early Parenthood

This study discusses young couples’ interactions with maternity and health services paying particular attention to men’s perspectives. Findings are based on research conducted in Scotland with men (aged 16–25) and their teenage partners (aged 16–19). Most young men were very involved in their child’s life and provided support and care to their partner during pregnancy and in early parenthood. Men often felt excluded or judged when accessing services, although positive experiences were reported too. The study discusses ways in which maternity and health services can be better attuned to meet the needs of young couples and be inclusive of men.     

A flexible framework for planning and evaluating early-stage health interventions: FRAME-IT

Health interventions exhibit three stages of maturity: early-, mid-, and late-stages. Early-stage interventions have innovative content necessitating evaluation; however existing evaluation frameworks omit constructs and guidelines relevant to this evaluation. Early-stage interventions require planning and evaluation that supports creating, testing, and exploring content to establish general feasibility and enable refinement for further testing, prior to randomised controlled trialling and wider dissemination. Feasibility, Reach-out, Acceptability, Maintenance, Efficacy, Implementation, Tailorability (FRAME-IT) was developed for a mixed methods feasibility study of a novel well-being intervention. FRAME-IT was conceived as a complementary framework to Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM; Glasgow et al., 1999) which is better suited for mid- and late- stage interventions. FRAME-IT is proposed to support: (1) early-stage intervention planning and design, by guiding research focus and data sourcing strategy with relevant constructs; (2) comprehensive evaluation, by including constructs appropriate for early-stage interventions, i.e. feasibility, acceptability, and tailorability; (3) future intervention scalability, by including and adapting some of RE-AIM’s constructs to encourage a smoother translation of research into practice as interventions are scaled-up.     

Engaging Parents in Parentline Plus’ Time to Talk Community Programme as Part of England’s Teenage Pregnancy Strategy: Lessons for Policy and Practice

Based on 65 interviews with professionals and parents conducted during 2007–2008, this 16‐month, mainly qualitative evaluation of Parentline Plus’ Time to Talk Community Programme (a preventative initiative within England’s teenage pregnancy strategy) found that a community development approach and an ethos of partnership with parents and professionals facilitated engagement. Respectful and realistic implementation involved skilled workers building relationships of trust. By consulting with other professionals and parents it was possible to establish local need and to build on existing provision. Initially, insufficient prior local consultation and negotiation created perceptions of an imposed initiative, led by outsiders, resulting in wary local parents and professionals. The engagement and evaluation processes are considered in relation to the short‐term nature of the initiative and potential conflicts between responding flexibly to the needs of parents and delivering targeted programmes.     

HIV in young men who have sex with men: a review of epidemiology, risk and protective factors, and interventions

Epidemiological studies have found that young men who have sex with men (YMSM) represent the majority of young people infected with HIV annually in the United States. Further, they are one of the few risk groups to show an increase in the rate of infections in recent years. In addition to these disparities in prevalence and infection rates, there is an inequity in prevention and intervention research on this population. The purpose of this article is to review the existing YMSM literature on HIV epidemiology, correlates of risk, and intervention research. The article concludes that promising future directions for basic research include a focus on multiple clustering health issues, processes that promote resiliency, the role of family influences, and the development of parsimonious models of risk. In terms of intervention research, the article suggests that promising future directions include Internet-based intervention delivery, integration of biomedical and behavioral approaches, and interventions that go beyond the individual level to address partnership, structural, community, and network factors.     

Mentoring Siblings of Gang Members: A Template for Reaching Families of Gang Members?

Mentoring has become a popular model of intervention to reduce the risk of offending, and has been proposed as an effective tool to tackle the risk of gang membership. This paper reviews the existing literature on mentoring and reports on a qualitative evaluation of a mentoring programme targeted at young people ‘at risk’ of gang membership in an English city. The study highlights important issues around these interventions. Although we found it a useful way to engage otherwise hard‐to‐reach families, important limitations remain: their potential labelling impact and their limited impact in isolation from other more ambitious measures.     

Sexual Self-Efficacy and Gender: A Review of Condom Use and Sexual Negotiation Among Young Men and Women in Sub-Saharan Africa

Sexual self-efficacy (SSE), one’s perceived control of or confidence in the ability to perform a given sexual outcome, predicts sexual behavior; however, important questions remain regarding whether gender modifies observed associations. In a comprehensive review of peer-reviewed HIV-prevention literature focusing on youth (ages 10 to 25) in sub-Saharan Africa, we measured and assessed the influence of SSE on condom use and sexual refusal, overall and by gender. Our results, after reviewing 63 publications, show that SSE is inconsistently measured. Most studies measured condom use self-efficacy (CUSE) (96.8%) and/or sexual refusal self-efficacy (SRSE) (63.5%). On average, young men had higher CUSE than young women, while young women had higher SRSE than young men. While cross-sectional studies reported an association between high SSE and sexual behaviors, this association was not observed in interventions, particularly among young women who face a disproportionate risk of HIV acquisition. In all, 25% of intervention studies demonstrated that fostering CUSE increased condom use among young men only, and one of two studies demonstrated that higher SRSE led to reduced frequency of sexual activity for both men and women. Future research and HIV-prevention interventions must be gender targeted, consider improving CUSE for young men, and move beyond limited individual-level sexual behavior change frameworks.     

Evaluating unintended program outcomes through Ripple Effects Mapping (REM): Application of REM using grounded theory

Several evaluation models exist for investigating unintended outcomes, including goal-free and systems evaluation. Yet methods for collecting and analyzing data on unintended outcomes remain under-utilized. Ripple Effects Mapping (REM) is a promising qualitative evaluation method with a wide range of program planning and evaluation applications. In situations where program results are likely to occur over time within complex settings, this method is useful for uncovering both intended and unintended outcomes. REM applies an Appreciative Inquiry facilitation technique to engage stakeholders in visually mapping sequences of program outcomes. Although it has been used to evaluate community development and health promotion initiatives, further methodological guidance for applying REM is still needed. The purpose of this paper is to contribute to the methodological development of evaluating unintended outcomes and extend the foundations of REM by describing steps for integrating it with grounded theory.     

Sexual needs, control, and refusal: how "doing" class and gender influences sexual risk taking

The poor are disproportionately affected by unintended pregnancy and sexually transmitted infections (STIs). We know relatively little, however, about the sexual processes behind these disparities. Despite studies of gender enactment's influence on sexual behaviors, few analyses examine the sexual "doing" of social class. We conducted sexual history interviews with 36 women and men, half middle class and half poor and working class. Most respondents reported that men have greater sexual appetites than women, but the middle class were more likely to cite social influences while the poor and working-class respondents primarily ascribed biological origins. The social construction of sexual controllability among the middle class contributed to perceptions that sex was a containable force. Poor and working-class women described men's sexual needs as physiologically irrepressible, which shaped sexual refusal. Our findings move beyond socioeconomic status (SES) as a "risk factor" and explore two examples of how gender and social class mediate people's sexual selves and health.     

Relative Efficacy of a Pregnancy,Sexually Transmitted Infection,or Human Immunodeficiency Virus Prevention–Focused Intervention on Changing Sexual Risk Behavior Among Young Adults

Abstract

Objectives: Despite findings suggesting that young adults are more concerned about experiencing an unplanned pregnancy or contracting a sexually transmitted infection (STI) than becoming human immunodeficiency virus (HIV) infected, no empirical work has investigated whether the specific focus of an intervention may be more or less efficacious at changing sexual behavior. Participants: Participants were 198 college students randomized to 1 of 4 conditions: pregnancy intervention, STI intervention, HIV intervention, or a control condition during 2008–2009. Methods: The authors compared the efficacy of 3 theory-based, sexual risk–reduction interventions that were exactly the same except for an exclusive focus on preventing pregnancy, STI, or HIV. Condom use and risky sexual behavior were assessed at baseline and 4-week and 8-week follow-up. Results: Participants exposed to the pregnancy or STI interventions reported greater condom use and less risky sexual behavior than those exposed to the HIV intervention. Conclusions: The focus of sexual risk–reduction interventions may lead to differential behavior change among young adults.     

Risk Factors and Life Processes Associated with Teenage Pregnancy: Results of a Prospective Study From Birth to 20 Years

Data gathered over the course of a 20‐year longitudinal study of 533 New Zealand women were used to (a) describe the extent and timing of pregnancies within the cohort up to age 20, and (b) examine the extent to which the risk of an early pregnancy was related to a range of social background, family, individual, and peer relationship factors measured over the course of childhood and adolescence. Results showed that by age 20, nearly a quarter of the sample had been pregnant at least once, with the majority of first pregnancies occurring between the ages of 17 and 20 years. The profile of those at greatest risk of a teenage pregnancy (<20 years) was that of an early‐maturing girl with conduct problems who had been reared in a family environment characterized by parental instability and maternal role models of young single motherhood. As young adolescents, these girls were characterized by high rates of sexual risk‐taking and deviant peer involvement. Exposure to social and individual adversity during both childhood and adolescence made independent contributions to an individual's risk of an early pregnancy. These findings were most consistent with a life course developmental model of the etiology of teenage pregnancy. Implications for teenage pregnancy prevention are discussed.     

Unintended consequences in traffic-light food labeling: A call for mixed methods in public health research

Abstract

Nudge theory describes how indirect suggestions and positive reinforcement can influence decision-making. We used nudge theory to implement a traffic-light labeling and choice architecture (modifying product placement) intervention at Harvard University cafeterias, but found no significant change in sales. Survey and focus group data showed that some students thought the labeling may exacerbate eating disorders, however, there is extremely limited research on potential negative consequences of labeling. One way to describe these findings is through 20th century philosopher Michel Foucault’s concept of biopower. Biopower manipulates cultural norms and nudges individuals to engage in self-surveillance and self-discipline, de facto subjugating themselves to certain ways of being. Biopower may lead to the creation of an in-group and an out-group based on who can adopt the new behaviors, such as healthy eating. Those in the out-group may face additional unintended consequences, highlighting the need for mixed-methods research to better evaluate public health interventions.     

“We believe in you,like really believe in you”: Initiating a realist study of (re)engagement initiatives for youth not in employment,education or training with experiences from northern Sweden

Due to a scarcity of rigorous evaluations and to commence a realist study addressing the lack of knowledge about the workings of interventions directed towards "NEET" youth, this research aimed to understand how and under what circumstances (re)engagement initiatives are expected to facilitate the social integration of young people who are in a situation that prevents them from entering into studies or work. By conducting the first phase in realist evaluation, qualitative interviews with five managerial stakeholders from two northern Swedish initiatives and reviews of documents were carried out for data collection. Using thematic analysis and retroductive reasoning, an intervention-context-actors-mechanisms-outcomes configuration was developed to elicit an initial programme theory that explained how the initiatives were presumed to operate and under what contextual contingencies. The results indicate that the intervention is expected to improve the youths’ wellbeing and engage them in work or studies by strengthening their competence and confidence in a caring and collaborative context. To incorporate the diverse voices and heterogeneous experiences of youth themselves, and ascertain whether the intervention works as intended, for whom, in what conditions and why, the results now need to be tested in selected cases and refined in subsequent phases of evaluation research.     

“Getting pregnant might make me seem more normal to them”: Attitudes,experiences, and gendered nuances regarding pregnancy and parenting among youths experiencing homelessness

Homelessness among youths exacerbates an array of challenging life experiences, notable examples of which are pregnancy and parenting. Research is lacking on young men’s attitudes and experiences, and also the influences which homeless youths’ gender identities and sexualities may have on their pregnancy and parenting outcomes and trajectories. This study qualitatively explores gender differentials, including youths’ gender identities and sexual orientations, with regard to their attitudes and experiences of pregnancy and parenting while homeless. Qualitative data were obtained from interviews with a diverse sample of 30 female, male, and transgender homeless youths, ages 18 to 21. Findings revealed that topics of pregnancy and parenting represent a wide range of complexities, different standards, and threats for homeless youths. Although pregnancy is often viewed positively within this community, it is received and experienced differently for each gender and sexuality. Results demonstrate that youths’ unimpeded access to and knowledge of all available reproductive and sexual health care services is essential. These services must be designed and delivered for youths of all gender identities and sexual orientations. Interventions and resources on parenting and co-parenting, particularly models that more inclusively engage a greater diversity of young parents’ involvement, are also urgently needed.     

The storyscapes of teenage pregnancy. On morality,embodiment, and narrative agency

Young women tell different stories about teenage pregnancies. Their stories are embedded in the storyscape of their environment, which offers a limited set of narratives. Normative discourses influence the stories young women tell about their pregnancies. Social norms and stigma play an important role in the construction of the meaning of teenage pregnancies. However, the embodiment of being pregnant constitutes meaning as well. This paper draws on findings from a qualitative study conducted in 2015 among 46 young Dutch women who got pregnant before their 20th birthday. Our study explores how young women navigate the moral arena when they are confronted with a teenage pregnancy and which role the embodiment of pregnancy plays in the construction of social meanings. The concept of storyscapes visualises how young women are constrained by their embeddedness in multiple storyscapes, defined by different and often contrasting audiences. Nevertheless, our study indicates that the momentum of pregnancy can offer agentic possibilities to take up another position towards their social environment and develop narrative agency.