HIV intervention (“FOYC+CImPACT”):
Focus on Youth in the Caribbean (“FOYC”) is an evidence-based, life skills curriculum designed to reduce risk taking behaviors related to HIV/STI transmission and teen pregnancy. Woven throughout FOYC is a decision-making model that provides guidance and practice in problem solving with a focus on how to obtain factual information on sexual health. Caribbean Informed Parents and Children Together (“CImPACT”) is a single session intervention including a 22-minute educational video filmed in The Bahamas which focuses on effective parent-adolescent communication and listening strategies related to difficult topics and safe-sex followed by two role-plays for the parent and youth, a discussion, and a condom demonstration . FOYC+CImPACT was adapted from Focus on Youth (FOY) plus Informed Parents and Children Together (ImPACT). FOY+ImPACT was selected to be part of the Centers for Disease Control and Prevention’s “Diffusion of Effective Behavioral Interventions (DEBI)” Portfolio.
Eighty-four grade six teachers who teach Health and Family Life Education (HFLE) classes in 24 schools on New Providence (the island where the capital city is located) completed a two-day teacher training workshop in October 2018. The training was provided by a diverse team of trainers and project staff, including three Bahamian Focus on Youth trainers who have extensive experience implementing FOYC+CImPCT and a US training specialist with expertise preparing educators to lead FOYC+CImPCT with remote and face-to-face training delivery. The training focused on increasing the teachers’ curriculum knowledge, building positive attitudes about the curriculum, and increasing skills and comfort to deliver the curriculum. Consistent with the Focus on Kids training guidelines, the training was comprised of clear expressed objectives, short lecturettes, group discussions, videos from the curriculum, skill and curriculum demonstration, active learning through skill practice, role plays and teach backs – all recommended as elements as effective skill-based training . Additionally, the training aligned with Adult Learning Theory in that the teachers were invited to give input into the training, they participated in several problem solving activities in an environment in which it was safe to make mistakes, and findings from any research in which they were involved could be immediately applied to their work in the classroom  . The teacher training covered: 1) the history and prevalence of HIV and HIV prevention in The Bahamas; 2) overview of FOYC including the research showing its effectiveness; 3) a “walk-through” of each session of FOYC with modeling of the “core” activities (activities considered to be critical to the success of FOYC, such as the Family Tree activity) and implementation guidance on how to avoid common pitfalls and maximize the impact of each session; 4) a didactic question-and-answer period regarding menstruation, contraception and condom-use; and, 5) a modeling of CImPACT, followed by implementation guidance. All teachers were given a copy of the FOYC teacher training manual. Teachers completed their consent forms, Measures C (Workshop Pre-evaluation), D (Workshop Post-evaluation), and E (Impression before Teaching) at the training workshop.
All participating teachers were presented a FOYC+ CImPACT 24/7 flash drive for “point-of-care” guidance as they prepared the lessons. FOYC+CImPACT 24/7 is a media-rich digital training program  accessible anytime, anywhere via DVD delivery. Such guaranteed access is important to teachers as the internet connection is sometime unreliable across all of the islands constituting The Bahamas. FOYC+CImPACT 24/7 was based on a similar evidence-based training and implementation support resource  and provides teachers with information and teaching points about each of the sessions, and intensive modeling and practice designed to develop key skills, such as answering sensitive questions, creating a safe and inclusive classroom, facilitation skills, etc. Teachers were oriented to the 3-hour DVD-based training during their in-person training. Providing accessible implementation support for educators is critical to correct curriculum implementation as it provides assistance when needed .
In preparation for the optimization trial in New Providence in Year 1, the US-Bahamas investigative team identified 81 low-performing and moderate-performing teachers and 10 high-performing teachers using our 7-item Pre-implementation School Screening tool. This stratification of teachers into three performance-levels was based on the teachers’ performance during the implementation study period (2011-2016) of a prior study using the same curriculum and teachers, and information regarding their continued implementation of FOYC in their classes over the past year.
In addition, the team held sessions with teachers and administrators from each school to ascertain: their comfort level regarding the curriculum; knowledge and exposure to the FOYC curriculum prior to the 2-day training; and, the execution or completion of the FOYC activities post training (November 2018-January 2019). This information allowed further identification of teachers who were most at-risk for implementation.
School coordinator and mentor training:
Twenty-four school coordinators (including two national school coordinators) were identified and trained for the purpose of tracking teachers’ implementation and progress biweekly, collecting teacher’s measures, and identifying and reporting issues/problems to the research team in New Providence. The coordinators also ensured that teachers were available for the training workshops and coordinated meetings within their schools.
In addition, high-performing teachers (mentors) were trained to provide “site-based assistance and mentorship” to at-risk and moderate-performing teachers. Mentors were trained for the purpose of identifying the challenges faced by teachers, assisting teachers in preparing for intervention sessions, promoting group activities and interaction among teachers, observing teachers teaching the session, modeling and providing guidance to improve curriculum delivery.
The school coordinator and mentor trainings were conducted by two Bahamian trainers who have extensive experience implementing FOYC+CImPACT. The school coordinator and mentor training sessions lasted about 4 hours and 3 hours respectively.
School-based intervention assignment.
Eighty-one at-risk and moderate-performing teachers in 24 schools were randomly assigned to four conditions of the Optimization trial in middle January-March 2019, using school-based randomization to avoid possible contamination. More schools were assigned to the control condition or to BFM because only six high-performing teachers/mentors were available for the optimization trial. Several high-performing teachers were unable to assist other teachers because of their workload/schedule. Nine schools were assigned to the control condition and nine schools to BFM only. Four schools were assigned to SAM only and two schools were assigned to both BFM and SAM condition. The research protocol was approved by the University of Massachusetts Medical School Human Investigation Committee and the Institutional Review Board of the Bahamian Princess Margaret Hospital, Public Hospitals Authority.
To assess implementation, all teachers were asked to complete a Teacher Implementation Checklist specific for each of the eight sessions of FOYC and CImPACT parent session after they had taught the session. The checklist includes the 30 activities identified by the developers as “core elements”. The teachers documented the activities that they covered in each session. Implementation dose was defined as the number of the 30 core activities that were taught during the optimization trial period (lasting two months, middle January to middle March, 2019).
Teacher’s Characteristics, Training Experience, and Perceptions. A pre-implementation questionnaire was used to collect information described in the extant research as influencing fidelity of intervention implementation: teacher’s level of formal education; years as a teacher; teacher’s attendance at FOYC training workshop; teachers’ perceptions of the importance of HIV prevention (very important, somewhat important, or not important) for grade six students in their schools; teacher’s comfort level in teaching the FOYC+CImPACT intervention; and, teacher’s sense of “ownership” of the curriculum (i.e., perceiving it as a “Bahamian intervention”) In bivariate analyses, responses for years as a teacher were grouped into three collapsed categories (1–10 years, 11-20 years, and >20 years), and two categories for perceptions of FOYC as a “Bahamian intervention” ( very or somewhat/not at all) due to low frequencies in some categories.
Pre-implementation questionnaires assessed teachers’ autonomy (four items) , perceived principal supportiveness (four items) [39,40], teachers’ confidence teaching/discussing five topics such as condom use, teen pregnancy and HIV/AIDS (five items) , teachers’ attitudes towards sex education in schools (eight items) , and teachers’ self-efficacy in teaching the FOYC+CImPACT intervention (three items) . Answers are given on a likert scale with five options (ranging from 1, totally disagree to 5, totally agree). Mean scores ranged between 1-5, with higher scores equating to more favorable perceptions/attitudes. The internal consistency of the scales is adequate (Cronbach’s alpha: autonomy, α=0.79; principal supportiveness α=0.80; confidence, α=0.87; attitudes towards sex education, α=0.77; self-efficacy α=0.73)
The effect of the implementation strategies (BMF and SAM) on teachers’ implementation was assessed using bivariate and multivariate statistics. ANOVA was used to compare the difference in number of core activities taught by the four groups of teachers. Multiple comparisons were conducted to examine the difference of all possible pairwise means. The effect of implementation strategies on teachers’ implementation, which was found to be significant at the bivariate level, was further examined using a general linear model (GLM) controlling for potential confounders, including teachers’ baseline perceptions and number of core activities taught before the start of the optimization trial. In addition, Pearson correlation analysis was conducted to examine the associations among teachers’ perceptions (autonomy, principal supportiveness, attitudes towards sex education in schools, confidence, and self-efficacy) and teachers’ implementation. Finally, a parsimonious structural equation model was constructed to examine the relationships among factors influencing teachers’ fidelity of implementation.