Using formative research to tailor a community intervention focused on the prevention of chronic disease

This case study attempts to illustrate and address in-depth the issues surrounding the collection, analysis, and application of formative research findings to program development and implementation. We provide an in-depth case study of tailoring a program for the residents of Berkshire County, Massachusetts. The formative research process includes collection and analysis of secondary data sources, extensive in-person interviews with community leaders, and in-depth focus groups with members of the population of interest. Findings from the formative research are then applied to tailoring the program materials and presentations and the training of the integrative team of health professionals that offer the program. Distinct components of program are tailored to the realities of the social, cultural, historical, and health and medical contexts in each community while other components of the program are tailored to individual participants. Overall, we believe this case study fully illustrates the utility of formative research in tailoring evidenced-based programs to increase program relevance and positive outcomes while maintaining fidelity to a program’s learning objectives and evaluation. We hope this in-depth account with specific examples proves useful as a guide to others when designing and conducting formative research to tailor health and medical interventions to the audience.     

Formative evaluation of a motivational intervention for increasing physical activity in underserved youth

The present study was designed to develop an innovative motivational intervention (based on Self-Determination Theory and Social Cognitive Theory) to increase physical activity (PA) in underserved adolescents. Sixty-four adolescents (35 females, 29 males; 50% minority; 65% on reduced lunch program; ages 11-13 yr) participated in either an 8-week motivational intervention after-school (n = 32) or a typical after-school program (n = 32). The conceptual framework for the intervention targeted the social environment (perceived autonomy, perceived social support, participation, fun), cognitive mediators (perceived choice, self-efficacy, and relatedness/belongingness), and motivational orientation (intrinsic motivation, commitment, positive self-concept). Formative evaluation data was collected by staff through daily forms throughout the 8-week program and through observational data completed by independent objective observers during 2 weeks of the program. The major themes that were identified addressed theoretical concepts regarding the intervention and logistical issues in delivering the intervention. The data revealed information regarding the importance of the cognitive appropriateness of the PA and motivational activities, the environmental climate for promoting nurturing relationships, developing specific strategies for increasing intrinsic rather than extrinsic reinforcement, and developing methods for preventing social "cliques" and gender conflicts to maintain an appropriate level of support in the social climate. Themes for training staff included focusing on team building, leadership, and nurturing. This formative evaluation is being used to formalize a randomized trial to test the effects of a student-centered motivational intervention on increasing PA in underserved 6th graders.     

A principles-focused evaluation of community mental health short-term case management

Principles-focused evaluations allow evaluators to appraise each principle that guides an organization or program. This study completed a principles-focused evaluation of a new community mental health intervention called Short Term Case Management (STCM) in Toronto, Canada. STCM is a time limited intervention for clients to address unmet needs and personalized goals over 3 months. Findings showcase that a principles-focused evaluation, assessing whether program principles are guiding, useful, inspiring, developmental and/or evaluable (GUIDE), is a practical formative evaluation approach. Specifically, offering an understanding of a novel intervention, including its key components of assessment and planning, support plan implementation and evaluation and care transitions. Findings also highlight that STCM may work best for those clients ready to participate in achieving their own goals. Future research should explore how best to apply the GUIDE framework to complex interventions, including multiple principles, to increase evaluation feasibility and focus.     

Building School,Family, and Community Partnerships: Developing a Theoretical Framework

School, family, and community partnerships are among the suite of strategies advocated for improved school outcomes in which social workers can play a valuable role. Such partnerships are complex to implement in practice and there is little systematic research to guide the practitioner. This study evaluated an early intervention partnership program involving school, family, community, and philanthropic partners implemented in two primary schools in rural Victoria, Australia. The findings highlighted challenges in the process of evaluation and program implementation and in the opportunities this provided to identify key enabling factors. These involved having: a shared vision and aims; democratic governance; a supportive policy and organisational environment including external funding; workers with skills and clear roles; activities for project momentum; and ongoing review and evaluation. These factors can be used by social workers and others working with schools as a valuable conceptual framework to facilitate school, family, and community partnership processes.     

Youth Participatory Action Research Findings as Mirror Material: Implications for Advancing Educational Equity Through Formative Interventions

Formative intervention research holds potential as a tool to disrupt systemic racism and advance equity in education. However, one aspect of formative interventions could be an impediment to realizing this potential, specifically the “mirror material”: data collected by outside researchers meant to provide participants a starting point to co-construct an understanding of a problem. Focusing on mirror material, this article draws insights from a youth participatory action research group to question whose knowledge should provide the grounding for formative interventions. Ultimately, we contend that youth of color should be involved in generating mirror material in equity-oriented formative interventions in education.     

Examining the efficacy of an mHealth media literacy education program for sexual health promotion in older adolescents attending community college

Objective: To determine the feasibility of a mobile health (mHealth), media literacy education program, Media Aware, for improving sexual health outcomes in older adolescent community college students. Participants: 184 community college students (ages 18–19) participated in the study from April–December 2015. Methods: Eight community college campuses were randomly assigned to either the intervention or a wait-list control group. Student participants from each campus completed web-based pretest and posttest questionnaires. Intervention group students received Media Aware in between questionnaires. Results: Several intervention effects of the Media Aware program were significant, including reducing older adolescents' self-reported risky sexual behaviors; positively affecting knowledge, attitudes, normative beliefs, and intentions related to sexual health; and increasing media skepticism. Some gender differences in the findings were revealed. Conclusions: The results from this study suggest that Media Aware is a promising means of delivering comprehensive sexual health education to older adolescents attending community college.     

A Population-Wide Screening and Tailored Intervention Platform for Eating Disorders on College Campuses: The Healthy Body Image Program

Abstract

Objectives: This article presents a new approach to intervention for eating disorders and body image concerns on college campuses, using a model of integrated eating disorder screening and intervention. Formative data on implementation feasibility are presented. Participants: College students enrolled at 2 universities between 2011 and 2012. Methods: The Healthy Body Image program is an evidence-based screening and intervention platform, enacted via community and online resources. An online screen was used to identify students at varying levels of risk or eating disorder symptom status; responses were used to direct students to universal or targeted online interventions or further evaluation. Universal prevention programs to improve healthy weight regulation and body image culture were offered to all students. Results: Formative data from 1,551 students illustrates the application of this model. Conclusions: The Healthy Body Image program is feasible to deliver and provides a comprehensive system of screening, evidence-based intervention, and community culture change.     

Development and piloting of a mother and child intervention to promote resilience in young children of HIV-infected mothers in South Africa

This paper describes the process of developing a parallel intervention for HIV-positive mothers and their young children (6-10 years) with a view to strengthening the relationship between them. Strong mother-child relationships can contribute to enhanced psychological resilience in children. The intervention was developed through action research, involving a situation analysis based on focus group discussions; intervention planning, piloting the intervention and a formative evaluation of the intervention. Participants supplied feedback regarding the value of the intervention in mother-child relationships. The findings obtained from the formative evaluation were used to refine the intervention. Two parallel programmes for mothers and children (15 sessions each) were followed by 10 joint sessions. The intervention for mothers focused on maternal mental health and the strengthening of their capacity to protect and care for their young children. The intervention for children addressed the development of their self-esteem, interpersonal relationships and survival skills. The formative evaluation provided evidence of good participation, support and group cohesion. Qualitative feedback indicated that the activities stimulated mother-child interaction. A similar intervention can easily be applied elsewhere using the detailed manual. The insights gained and lessons learnt related to mother and child interaction within an HIV-context that emerged from this research, can be valuable in other settings, both in Sub-Saharan Africa and elsewhere.     

Development and piloting of a mother and child intervention to promote resilience in young children of HIV-infected mothers in South Africa

This paper describes the process of developing a parallel intervention for HIV-positive mothers and their young children (6–10 years) with a view to strengthening the relationship between them. Strong mother–child relationships can contribute to enhanced psychological resilience in children. The intervention was developed through action research, involving a situation analysis based on focus group discussions; intervention planning, piloting the intervention and a formative evaluation of the intervention. Participants supplied feedback regarding the value of the intervention in mother–child relationships. The findings obtained from the formative evaluation were used to refine the intervention. Two parallel programmes for mothers and children (15 sessions each) were followed by 10 joint sessions. The intervention for mothers focused on maternal mental health and the strengthening of their capacity to protect and care for their young children. The intervention for children addressed the development of their self-esteem, interpersonal relationships and survival skills. The formative evaluation provided evidence of good participation, support and group cohesion. Qualitative feedback indicated that the activities stimulated mother–child interaction. A similar intervention can easily be applied elsewhere using the detailed manual. The insights gained and lessons learnt related to mother and child interaction within an HIV-context that emerged from this research, can be valuable in other settings, both in Sub-Saharan Africa and elsewhere.     

Connecting the dots: implementing and evaluating a network intervention to foster scientific collaboration and productivity

This article presents the design and implementation of a network intervention to foster scientific collaboration at a research university, and describes an experimental framework for rigorous evaluation of the intervention’s impact. Based on social network analysis of publication and grant data, an innovative type of research funding program was developed as a form of alteration of the university’s collaboration network. The intervention consisted in identifying research communities in the network and creating a new collaborative relation between pairs of unconnected researchers in selected communities. The new collaboration was created to maximally increase the overall cohesion of the target research community. In order to evaluate the impact of the program, we designed a randomized experiment with treatment and control communities based on the Rubin Causal Model approach. The paper describes the intervention design, reports findings from the program implementation, and discusses the statistical framework for future evaluation of the intervention.     

“We don't want to talk about that”: Overcoming barriers to rural aging research and interventions on sensitive topics

Geographical, economic, social and cultural barriers to accessing services in rural areas are widely reported. Less widely discussed are dilemmas posed by individual and community reluctance to address sensitive health issues. This article, focusing on the highly sensitive area of mental health, and employing a participatory action approach, describes the natural history of a project, the Mental Health and Aging Initiative (MHAI) to enhance awareness of mental health issues in rural Kentucky-Appalachian communities and overcome the reluctance of individuals in these communities to seek assistance. Funded by the United States Department of Agriculture (USDA), MHAI involved an educational intervention to improve knowledge about mental health and aging in rural Appalachian counties. The need to overcome significant community reluctance to engage in discussion of mental health resulted in significant modification of the protocol. The intervention was grounded in recognition of four key aspects of the local situation: (1) the need to understand the sensitivity of mental health as an element of rural culture; (2) the critical role of local community leaders as points of entry, acceptance, and action; (3) the need to overcome social stigma and reframe the topic of mental health in a more positive light; and (4) the need for methodological innovation in developing an empowering educational action plan oriented toward community-wide long-term impact. The intervention model that emerged from these considerations was based on engaging community leaders, providing educational and technical resources, and nurturing the acceptance by individual rural residents of responsibility for monitoring community mental health. This motif became a central theme in a strategy designed to facilitate culture change and acceptance of mental health as a community concern. It involved active engagement of community representatives in defining and implementing an intervention consistent with participatory action research as a means of empowering rural residents in monitoring and addressing sensitive health care issues. Given that many issues in rural health are difficult to address because of such sensitivity, the approach described is considered to have application in other contexts.     

Exploring the unmet needs for creating an enabling environment for nurturing care to promote migrant child health in Bishkek,Kyrgyzstan: A theory-guided community-based participatory action research

Empirical evidence on community-driven child health promotion programs in disadvantaged migrant populations is limited despite various promotional strategies. Therefore, we implemented a developmental process to shape child health interventions using theory-guided community-based participatory action research (CBPAR) in a migrant community in Bishkek, Kyrgyzstan between 2015 and 2019.The collaborative and iterative CBPAR process was conducted through participatory workshops and focus group discussions with support from trusting and collegial partnerships between community members and the research team. The goal and scope of the intervention was guided by enabling environments for nurturing care, including the four domains of caregivers’ capabilities, empowered communities, supportive services, and enabling policies. Diverse interests and needs identified by community members were aggregated in the theoretical model and reflected in the intervention.Community-driven intervention is perceived as a culturally acceptable, sustainable, sensitive and relevant approach to solve problems. There are several challenges in conducting the CBPAR, such as the effort and time spent on building partnerships, co-learning and mutual understanding, and the power equilibrium involved. Despite this, the success of the CBPAR process provided opportunities for community mobilization, empowerment and sustainability of the intervention. Evaluation of the process and outcomes of the intervention provided community health researchers and practitioners with evidence of the theory-guided community participatory approach.     

Voices from the Community

Summary

When community members are allowed to participate in the planning and implementation process of a program, they are empowering themselves and their community. The CHAMP Family Program uses a collaborative programming approach with a focus on building the capacities of community members to deliver a family-based HIV prevention program. The CHAMP Program has a Collaborative Board that oversees all aspects of the research project. Using an empowerment framework, this article explores Community Board members' perspectives on their experience in working on CHAMP. Recommendations to researchers in the form of ten key ingredients for community collaboration are presented. The key points primarily focus on building trust with the community, recognizing community strengths, developing skills, building intragroup relations, and involving the community as partners from the beginning to the end.     

IMPLEMENTATION OF PARENT MANAGEMENT TRAINING AT THE NATIONAL LEVEL: THE CASE OF NORWAY

This article describes early aspects of the nationwide implementation of an evidence‐based program (EBP) in Norway and the design for studying program fidelity over time. The EBP is the Parent Management Training, Oregon Model (PMTO). The project is a combination of a ‘top down’ initiative at the governmental and ministry level, and a ‘bottom up’ initiative from practitioners seeking effective interventions in the prevention and remediation of behavior problems in children and youth. The main components of the implementation strategy were to (a) establish a national implementation and research center; (b) provide for regional and local participation at county and municipal levels; (c) establish a comprehensive therapist recruitment, training, and maintenance program; (d) create a network for collaboration, supervision, and quality control; (e) conduct clinical outcome research; and (f) study the implementation process. Following the training of three successive generations of PMTO specialists, a study was designed to examine how individual, family, interventionist, organizational, and community characteristics influence program adoption and implementation, as well as how these factors impact upon how PMTO specialists provide the intervention to families with competent adherence to the model. Within the framework of the collaborative North American and Norwegian project, challenges and facilitators in the process of the continental crossing of the PMTO model are discussed.     

Measuring Fidelity in Research Studies: A Field Guide to Developing a Comprehensive Fidelity Measurement System

An accurate assessment of fidelity, combined with a high degree of fidelity to the intervention, is critical to the reliability, validity, replicability, and scale-up of the results of an intervention research study. However, extant measures of fidelity are infrequently applicable to the program or intervention being studied, and the literature lacks guidance on the specific process of developing a system to measure fidelity in a manualized intervention. This article describes a five-step process to define the scope, identify components, develop tools, monitor fidelity, and analyze outcomes to develop a comprehensive fidelity measurement system for an intervention. The process describes the components, measures and key decisions that form a comprehensive fidelity measurement system. In addition, the process is illustrated by a case study of the development of a fidelity measurement system for a research study testing Pathways Triple P, a behavioral parent-training program, with a population of child welfare-involved families. Pathways Triple P is a common, manualized intervention and the process described in this article can be generalized to other manualized interventions. The implications and requirements for accurately assessing and monitoring fidelity in research studies and practice are discussed.     

Exposure to Community Violence,Suicidality, and Psychological Distress Among African American and Latino Youths: Findings From the CDC Youth Violence Survey

The present investigation explored risk and protective factors for suicidal ideation and behavior in a sub-sample of African American and Latino adolescents (n = 2,626) who participated in the 2004 Centers for Disease Control Youth Violence Survey. Structural equation modeling was used to explore exposure to violence at the community level as a contextual factor that could potentially influence depressive symptomatology, substance abuse, parental support, social support, and suicidality among study participants. Findings indicated that exposure to violence at the community level was not directly related to suicidality among this population of urban adolescents. However, it was directly related with several other variables under study in the model, which in turn were directly related with suicidality. Tests of invariance revealed several across-group differences, particularly by race and gender, in how the identified risk and protective factors in the model related to suicidality. Implications for research and practice with urban, ethnic minority, adolescent populations are discussed.     

A multi-level examination of how the organizational context relates to readiness to implement prevention and evidence-based programming in community settings

Prior theoretical and empirical research suggests that multiple aspects of an organization's context are likely related to a number of factors, from their interest and ability to adopt new programming, to client outcomes. A limited amount of the prior research has taken a more community-wide perspective by examining factors that associate with community readiness for change, leaving how these findings generalize to community organizations that conduct prevention or positive youth development programs unknown.Thus for the current study, we examined how the organizational context of the Cooperative Extension System (CES) associates with current attitudes and practices regarding prevention and evidence-based programming. Attitudes and practices have been found in the empirical literature to be key indicators of an organization's readiness to adopt prevention and evidence-based programming. Based on multi-level mixed models, results indicate that organizational management practices distinct from program delivery may affect an organization's readiness to adopt and implement new prevention and evidence-based youth programs, thereby limiting the potential public health impact of evidence-based programs. Openness to change, openness of leadership, and communication were the strongest predictors identified within this study. An organization's morale was also found to be a strong predictor of an organization's readiness. The findings of the current study are discussed in terms of implications for prevention and intervention.     

Critical Variables for Infusing Community Content into a Clinical Program

ABSTRACT

This empirical study seeks to identify effective methods for infusing community material into a clinical social work program. It draws from Diffusion of Innovation Theory (Rogers, 1995b) and the Transtheoretical Model (Prochaska, DiClemente, &;Norcross, 1992) to guide implementation. Based on qualitative and quantitative data from a variety of sources, the results identify variables critical in the change process and some preliminary outcomes of that change. Findings suggest that teaching community content can be enhanced through developing a pool of outside community guest speakers and field trips, addressing the varying faculty development needs of professors teaching macro and micro social work courses, and defining and redefining the concept of community during implementation and change processes.     

Updating the FORECAST formative evaluation approach and some implications for ameliorating theory failure,implementation failure,and evaluation failure

Historically, there has been considerable variability in how formative evaluation has been conceptualized and practiced. FORmative Evaluation Consultation And Systems Technique (FORECAST) is a formative evaluation approach that develops a set of models and processes that can be used across settings and times, while allowing for local adaptations and innovations. FORECAST integrates specific models and tools to improve limitations in program theory, implementation, and evaluation. In the period since its initial use in a federally funded community prevention project in the early 1990s, evaluators have incorporated important formative evaluation innovations into FORECAST, including the integration of feedback loops and proximal outcome evaluation. In addition, FORECAST has been applied in a randomized community research trial. In this article, we describe updates to FORECAST and the implications of FORECAST for ameliorating failures in program theory, implementation, and evaluation.