title: Factors influencing implementation dose and fidelity thereof and related student outcomes of an evidence-based national HIV prevention program.
abstract: BACKGROUND
  Teachers' implementation of evidence-based prevention programs in schools is inconsistent. Using data gathered from the national implementation among grade six students in The Bahamas of an evidence-based HIV intervention [Focus on Youth in the Caribbean (FOYC)], this study examines differences in the degree of implementation ("dose") and adherence to the core activities ("fidelity of implementation") by teachers according to theoretically and historically relevant teachers' characteristics, attitudes, and experiences pre-intervention and post-intervention. The relationship of implementation dose and implementation fidelity is assessed according to student outcomes.
  
  
  METHODS
  Beginning in 2008, the Bahamian Ministry of Education (MOE) included FOYC in the grade six curriculum nationwide. Consistent with standard practice, teachers were offered MOE training workshops in FOYC prior to delivery. The MOE conducted an anonymous curricular assessment among the grade six students at the beginning and end of the school year. Teachers agreeing to participate in the research component were asked to complete a pre-implementation and post-implementation assessment of attitudes and prior experiences.
  
  
  RESULTS
  Teachers taught 15.6 out of 30 core activities, 24 out of the 46 total activities, and 4.6 out of 8 sessions on average. Three teachers' implementation groups were identified: 1) High Implementation Group (31.7% of the teachers), characterized by high levels of implementation dose and fidelity of implementation; 2) Moderate Implementation Group (52.8%), showing moderate levels of implementation dose but high levels of fidelity of implementation; and 3) Low Implementation Group (15.6%), with low levels of implementation dose and fidelity of implementation. Low Implementation Group teachers compared to teachers in the two higher performing groups had less training in interactive teaching, limited prior exposure to the FOYC curriculum, incomplete attendance at FOYC training workshops, and low levels of comfort in teaching FOYC lessons. Students taught by teachers in the Low Implementation Group demonstrated poorer outcomes relevant to the four student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection if they were to have sex).
  
  
  CONCLUSIONS
  Both implementation dose and implementation fidelity are related to student outcomes. Teachers at risk for limited implementation can be identified pre-intervention, thus opening the possibility for focused pre-intervention training.
authors.affiliation: Department of Pediatrics, Wayne State University School of Medicine, 4707 Saint Antoine Street, Detroit, MI, 48201, USA. bwang@med.wayne.edu.
authors.forename: Bo
authors.initials: B
authors.lastname: Wang
authors.affiliation: Department of Pediatrics, Wayne State University School of Medicine, 4707 Saint Antoine Street, Detroit, MI, 48201, USA. bstanton@med.wayne.edu.
authors.forename: Bonita
authors.initials: B
authors.lastname: Stanton
authors.affiliation: Office of HIV/AIDS, Ministry of Health, Shirley Street, Nassau, The Bahamas. lyndeveaux@yahoo.com.
authors.forename: Lynette
authors.initials: L
authors.lastname: Deveaux
authors.affiliation: Office of HIV/AIDS, Ministry of Health, Shirley Street, Nassau, The Bahamas. m.g.poitier@gmail.com.
authors.forename: Maxwell
authors.initials: M
authors.lastname: Poitier
authors.affiliation: Office of HIV/AIDS, Ministry of Health, Shirley Street, Nassau, The Bahamas. slunn@coralwave.com.
authors.forename: Sonja
authors.initials: S
authors.lastname: Lunn
authors.affiliation: Department of Pediatrics, Wayne State University School of Medicine, 4707 Saint Antoine Street, Detroit, MI, 48201, USA. vkoci@med.wayne.edu.
authors.forename: Veronica
authors.initials: V
authors.lastname: Koci
authors.affiliation: Office of HIV/AIDS, Ministry of Health, Shirley Street, Nassau, The Bahamas. rbadderley@gmail.com.
authors.forename: Richard
authors.initials: R
authors.lastname: Adderley
authors.affiliation: Department of Pediatrics, Wayne State University School of Medicine, 4707 Saint Antoine Street, Detroit, MI, 48201, USA. lkaljee@yahoo.com.
authors.forename: Linda
authors.initials: L
authors.lastname: Kaljee
authors.affiliation: Department of Pediatrics, Wayne State University School of Medicine, 4707 Saint Antoine Street, Detroit, MI, 48201, USA. smarshal@med.wayne.edu.
authors.forename: Sharon
authors.initials: S
authors.lastname: Marshall
authors.affiliation: Department of Pediatrics, Wayne State University School of Medicine, 4707 Saint Antoine Street, Detroit, MI, 48201, USA. xiaoli@med.wayne.edu.
authors.forename: Xiaoming
authors.initials: X
authors.lastname: Li
authors.affiliation: Department of Education, Ministry of Education, Thompson Boulevard, PO Box N-3913, Nassau, The Bahamas. grolle54@gmail.com.
authors.forename: Glenda
authors.initials: G
authors.lastname: Rolle
mesh_terms: D001444:Bahamas / Q000453:epidemiology; D003479:Curriculum; D055317:Evidence-Based Practice / Q000379:methods; D005178:Faculty; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D016730:Program Development; D015397:Program Evaluation; D012572:School Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D013334:Students / Q000523:psychology / Q000706:statistics & numerical data