Susan M. Breitenstein

Implementation fidelity in community-based interventions

Implementation fidelity is the degree to which an intervention is delivered as intended and is critical to successful translation of evidence-based interventions into practice. Diminished fidelity may be why interventions that work well in highly controlled trials may fail to yield the same outcomes when applied in real life contexts. The purpose of this paper is to define implementation fidelity and describe its importance for the larger science of implementation, discuss data collection methods and current efforts in measuring implementation fidelity in community-based prevention interventions, and present future research directions for measuring implementation fidelity that will advance implementation science.

The Chicago Parent Program: Comparing 1-Year Outcomes for African American and Latino Parents of Young Children

Data were merged from two prevention randomized trials testing 1-year outcomes of a parenting skills program, the Chicago Parent Program (CPP) and comparing its effects for African-American (n = 291) versus Latino (n = 213) parents and their preschool children. Compared to controls, intervention parents had improved self-efficacy, used less corporal punishment and more consistent discipline, and demonstrated more positive parenting. Intervention children had greater reductions in behavior problems based on parent-report, teacher-report, and observation. Although improvements from the CPP were evident for parents in both racial/ethnic groups, Latino parents reported greater improvements in their childrens behavior and in parenting self-efficacy but exhibited greater decreases in praise. Findings support the efficacy of the CPP for African American and Latino parents and young children from low-income urban communities.

Digital delivery methods of parenting training interventions: A systematic review

BACKGROUND Alternative delivery methods to implement evidence-based parent training programs are emerging to address barriers related to parent attendance in face-to-face administration. The purpose of this systematic review is to summarize and critically evaluate the research on the use of technology and digital delivery methods for parenting training and offer recommendations for advancing the science and practice of parent training using digital delivery methods. METHODS A systematic review was conducted using PubMed, PsychInfo, CINAHL, Scopus database, and ERIC to identify articles published between 2000 and 2012 reporting studies using digital methods to deliver parent training. Eleven studies were included in the review and were analyzed related to the digital delivery methods used, participant rates of intervention completion (dose), and the efficacy for improving parent and child outcomes. FINDINGS The final sample of papers (n = 11) represent seven parent training interventions and nine digital delivery methods. Six of the nine used the Internet as the primary delivery method. The proportion of digitally delivered content completion ranged from 41.7% to 99.2%. Of the studies (n = 4) that reported behavioral outcomes of the interventions, the average effect size (Cohens d) for child outcomes was .61 and for parent outcomes .46. LINKING EVIDENCE TO ACTION Findings from this review indicate that the use of technology and digital delivery is a growing and emerging method of delivering parent training interventions with high potential for increasing reach and sustainability as we implement interventions in real world settings. Gaps in the studies reviewed highlight the need for consistency of dose calculations using digital methods, more research related to efficacy and comparative effectiveness studies of delivery methods.

Web-Based Delivery of a Preventive Parent Training Intervention: A Feasibility Study

PROBLEM Low enrollment and participation are common in face-to-face parenting interventions. Developing innovative delivery methods is one way to address participation barriers. The purpose of this study was to test the feasibility of a Web-based delivery model for an evidence-based behavioral parent training program. METHODS Parents (n = 9) completed two Web-based prototype sessions of the Chicago Parent Program delivered on an Android tablet over 2 weeks, and then participated in a post-intervention focus group. Quantitative and qualitative data were collected. FINDINGS The Web-based delivery adaptation was feasible and useful for low-income urban parents. CONCLUSIONS Our preliminary findings suggest that Web-based delivery is a feasible approach to integrating mental health prevention into systems of care. Translating interventions to alternative delivery platforms is promising for nursing to increase access to evidence-based interventions.

Promoting Mental Health in Early Childhood Programs Serving Families From Low-income Neighborhoods

Although the majority of young children growing up in low-income communities will not experience mental health problems, a proportion of children will develop problems that can be painful for families and costly to society. There is growing consensus that preventive interventions in the first 5 years of life are the most cost-effective strategy for reducing childrens mental health problems. The purposes of this article are to (a) present the case for providing health promotion and preventive interventions to economically disadvantaged parents of young children as standard practice in early childhood programs and (b) describe the feasibility and utility of incorporating mental health promotion services in child care centers serving low-income families using the Chicago Parent Program (CPP) as an example. The CPP is an evidence-based intervention designed in collaboration with low-income, ethnic minority parents to promote positive parenting skills and reduce behavior problems in young children. J Am Psychiatr Nurses Assoc, 2007; 13(5), 313-320. DOI: 10.1177/1078390307306996

Understanding Disruptive Behavior Problems in Preschool Children

Disruptive behavior problems in young children are the number one reason for referral to mental health agencies. However, owing to difficulties differentiating clinically significant disruptive behaviors from typical development, a significant proportion of young children with disruptive behavior problems go unidentified and untreated. Research supports the existence of disruptive behavior disorders in young children, and early identification and treatment are critical to interrupt the trajectory of early problems to more significant and impairing difficulties. The purposes of this article were to identify and discuss disruptive behavior problems in preschool children and to introduce readers to current definitions of disruptive behavior problems and emotion regulation. A review of risk factors and underlying emotion and behavior regulation difficulties implicated in the development of disruptive behavior problems is provided. Furthermore, clinical implications for nurses in the identification of disruptive behavior problems in preschool children for pediatric nurses are discussed.

Parent Use and Efficacy of a Self-Administered, Tablet-Based Parent Training Intervention: A Randomized Controlled Trial

BACKGROUND Parent training programs are traditionally delivered in face-to-face formats and require trained facilitators and weekly parent attendance. Implementing face-to-face sessions is challenging in busy primary care settings and many barriers exist for parents to attend these sessions. Tablet-based delivery of parent training offers an alternative to face-to-face delivery to make parent training programs easier to deliver in primary care settings and more convenient and accessible to parents. We adapted the group-based Chicago Parent Program (CPP) to be delivered as a self-administered, tablet-based program called the ezParent program. OBJECTIVE The purpose of this study was to (1) assess the feasibility of the ezParent program by examining parent satisfaction with the program and the percent of modules completed, (2) test the efficacy of the ezParent program by examining the effects compared with a control condition for improving parenting and child behavior in a sample of low-income ethnic minority parents of young children recruited from a primary care setting, and (3) compare program completion and efficacy with prior studies of the group-based CPP. METHODS The study used a two-group randomized controlled trial (RCT) design with repeated measures follow up. Subjects (n=79) were randomly assigned to an intervention or attention control condition. Data collection was at baseline and 12 and 24 weeks post baseline. Parents were recruited from a large, urban, primary care pediatric clinic. ezParent module completion was calculated as the percentage of the six modules completed by the intervention group parents. Attendance in the group-based CPP was calculated as the percentage of attendance at sessions 1 through 10. Satisfaction data were summarized using item frequencies. Parent and child data were analyzed using a repeated measures analysis of variance (RM-ANOVA) with simple contrasts to determine if there were significant intervention effects on the outcome measures. Effect sizes for between group comparisons were calculated for all outcome variables and compared with CPP group based archival data. RESULTS ezParent module completion rate was 85.4% (34.2/40; 95% confidence interval [CI] = 78.4%-93.7%) and was significantly greater (P<.05) than face-to-face CPP group attendance (135.2/267, 50.6%) attendance of sessions; 95% CI = 46.8%-55.6%). ezParent participants reported the program as very helpful (35/40, 88.0%) and they would highly recommend the program (33/40, 82.1%) to another parent. ezParent participants showed greater improvements in parenting warmth (F1,77 = 4.82, P<.05) from time 1 to 3. No other significant differences were found. Cohens d effect sizes for intervention group improvements in parenting warmth, use of corporal punishment, follow through, parenting stress, and intensity of child behavior problems were comparable or greater than those of the group-based CPP. CONCLUSIONS Data from this study indicate the feasibility and acceptability of the ezParent program in a low-income, ethnic minority population of parents and comparable effect sizes with face-to-face delivery for parents.

Study protocol for a comparative effectiveness trial of two parent training programs in a fee-for-service mental health clinic: can we improve mental health services to low-income families?

BackgroundUntreated behavioral and mental health problems beginning in early childhood are costly problems affecting the long-term health and wellbeing of children, their families, and society. Although parent training (PT) programs have been demonstrated to be a cost-effective intervention modality for treating childhood behavior problems, they have been less effective for children from low-income and underserved racial and ethnic populations. The purpose of this randomized trial is to compare the effectiveness, cost, and social validity of two manualized evidence-based PT programs that were developed and tested on different populations and employ different delivery models: (1) The Chicago Parent Program (CPP), a group-based program developed in collaboration with a community advisory board of African-American and Latino parents; and (2) Parent-Child Interaction Therapy (PCIT), an individualized parent-child coaching model considered to be ‘the gold standard’ for parents of children with externalizing behavior problems.MethodsThis trial uses an experimental design with randomization of parents seeking behavioral treatment for their 2- to 5-year-old children at a mental health clinic in Baltimore, MD (80% African-American or multi-racial; 97% receiving Medicaid). Using block randomization procedures, 262 parents are randomized to CPP or PCIT. Clinicians (n = 13) employed in the mental health clinic and trained in CPP or PCIT are also recruited to participate. Primary outcomes of interest are reductions in child behavior problems, improvements in parenting, perceived value of the interventions from the perspective of parents and clinicians, and cost. Parent distress and family social risk are assessed as modifiers of treatment effectiveness. We hypothesize that CPP will be at least as effective as PCIT for reducing child behavior problems and improving parenting but the programs will differ on cost and their social validity as perceived by parents and clinicians.DiscussionThis is the first study to compare the effectiveness of a PT program originally designed with and for parents from underserved racial and ethnic populations (CPP) against a well-established program considered to be the ‘the gold standard’ (PCIT) with a high-risk population of parents. Challenges related to conducting a randomized trial in a fee-for-service mental health clinic serving urban, low-income families are discussed.Trial registrationNCT01517867

Attention to fidelity: why is it important.

Clinical trials are epitomized by control of extraneous contextual and demographic variables. Participants in intervention and control or comparison groups are assessed for similarities and differences. The content, dose, and duration of interventions are prescribed explicitly. Interventionists are trained, supervised, evaluated, and in some cases retrained during the intervention to ensure adherence to the protocol. Outcome variables are assessed before and after the intervention, and those variables that could influence the results are controlled statistically. Implementing interventions found to be effective in research provides an empirical base for practice, yet control in practice is elusive. Fidelity is paramount in translating research to practice. Fidelity (sometimes called integrity; or delivery, treatment, intervention, or implementation fidelity) is defined as the degree to which an intervention or procedure is delivered as intended. One of the most important factors when implementing empirically supported interventions is that they are delivered with fidelity. In fact, lack of fidelity to an intervention model may underlie why interventions that work well in highly controlled research trials fail to produce the same outcomes in real-world settings. Therefore, monitoring and assuring fidelity is critical in replicating the beneficial results of an intervention in a variety of settings and populations. Therefore, developing a comprehensive fidelity plan is critical for dissemination and translation into practice. Fidelity is an important component of implementation science (Eccles & Mittman, 2006). Implementation science is ‘‘the scientific study of methods to promote the systematic uptake of research findings (and other EBPs) into routine practice, and, hence, to improve the quality and effectiveness of health services and care’’ (Eccles & Mittman, 2006, {2). In other words, implementation science is the study of how research and evidence-based practices (EBPs) are adopted and used in day-to-day practice with fidelity being key to achieving the positive effects in the adoption and implementation process.

Developing the eCPP: Adapting an evidence-based parent training program for digital delivery in primary care settings

BACKGROUND Developing innovative delivery methods is needed to overcome time and logistic barriers to in-person participation in evidence-based parent training (PT) programs. PURPOSE The purpose of this paper is to (a) describe the systematic process for adapting an evidence-based group PT program (the Chicago Parent Program) to a tablet-based delivery format, (b) present the adapted program, and (c) discuss opportunities and challenges of adapting evidence-based programs for alternative delivery methods. METHODS To ensure consistency with the original program and relevance to the intended program recipients, three groups-parents (n = 10), CPP developers (n = 3), and digital delivery experts- were engaged throughout the systematic steps of the delivery adaptation of the Chicago Parent Program (eCPP). Group meetings were used to identify the programs core components, develop the adaptation program model, assess potential mismatches for the new delivery context, and adapt the original program model and materials. RESULTS The final eCPP is a six-module Internet-based intervention that includes: interactive activities, video examples and explanations of parenting strategies, reflection questions, assessment of parent knowledge with feedback, and module practice assignments. LINKING EVIDENCE TO ACTION Developing innovative delivery approaches for evidenced-based interventions are promising to increase intervention sustainability and participant access and engagement. It is critical that these adaptations are systematic and developed with expert consultation and community input.