Primary aim results of a clustered SMART for developing a school-level, adaptive implementation strategy to support CBT delivery at high schools in Michigan

Abstract

Background Schools increasingly provide mental health services to students, but often lack access to implementation strategies to support school-based (and school professional [SP]) delivery of evidence-based practices. Given substantial heterogeneity in implementation barriers across schools, development of adaptive implementation strategies that guide which implementation strategies to provide to which schools and when may be necessary to support scale-up. Methods A clustered, sequential, multiple-assignment randomized trial (SMART) of high schools across Michigan was used to inform the development of a school-level adaptive implementation strategy for supporting SP-delivered cognitive behavioral therapy (CBT). All schools were first provided with implementation support informed by Replicating Effective Programs (REP) and then were randomized to add in-person Coaching or not (phase 1). After 8 weeks, schools were assessed for response based on SP-reported frequency of CBT delivered to students and/or barriers reported. Responder schools continued with phase 1 implementation strategies. Slower-responder schools (not providing ≥ 3 CBT components to ≥10 students or >2 organizational barriers identified) were re-randomized to add Facilitation to current support or not (phase 2). The primary aim hypothesis was that SPs at schools receiving the REP + Coaching + Facilitation adaptive implementation strategy would deliver more CBT sessions than SPs at schools receiving REP alone. Secondary aims compared four implementation strategies (Coaching vs no Coaching × Facilitation vs no Facilitation) on CBT sessions delivered, including by type (group, brief and full individual). Analyses used a marginal, weighted least squares approach developed for clustered SMARTs. Results SPs (n = 169) at 94 high schools entered the study. N = 83 schools (88%) were slower-responders after phase 1. Contrary to the primary aim hypothesis, there was no evidence of a significant difference in CBT sessions delivered between REP + Coaching + Facilitation and REP alone (111.4 vs. 121.1 average total CBT sessions; p = 0.63). In secondary analyses, the adaptive strategy that offered REP + Facilitation resulted in the highest average CBT delivery (154.1 sessions) and the non-adaptive strategy offering REP + Coaching the lowest (94.5 sessions). Conclusions The most effective strategy in terms of average SP-reported CBT delivery is the adaptive implementation strategy that (i) begins with REP, (ii) augments with Facilitation for slower-responder schools (schools where SPs identified organizational barriers or struggled to deliver CBT), and (iii) stays the course with REP for responder schools. Trial registration ClinicalTrials.gov, NCT03541317, May 30, 2018.

Closing the Gap Between Classroom-Based Physical Activity Intervention Adoption and Fidelity in Low-Resource Schools

“…In line with prior studies (Kilbourne et al, 2018;Smith et al, 2022), classroom teachers are currently being supported in the development of strategic thinking, leadership skills, and reduction of barriers related to tailored InPACT delivery through a five-step process. This process includes helping classroom teachers set measurable goals (e.g., reducing activity break transition times to increase instructional time), identifying teacher strengths to build self-efficacy, aligning tailored InPACT delivery with existing school and administrator values and priorities, providing guidance on overcoming school barriers to tailored InPACT delivery, and increasing engagement with administrators and other support staff.…”

“…Guided by the social learning and diffusion of innovations theories (Bandura, 1977;Rogers, 2003), enhanced REP is a multifaceted implementation strategy that bundles tailored program packaging and teacher training with implementation facilitation to provide schools with ongoing support (Kilbourne et al, 2014). Hence, enhanced REP addresses fundamental barriers to school-based intervention delivery and has been shown to improve the uptake of behavioral interventions in low-resource schools (Smith et al, 2022). We applied the enhanced REP framework to tailor InPACT program packaging, teacher training, technical assistance, and implementation facilitation processes to mitigate implementation barriers unique to low-resource schools .…”

“…Previous research has demonstrated that teachers are more successful in implementing PA breaks when they are provided monthly support from a facilitator compared with teachers who received one-time training only (Delk et al, 2014). Enhanced REP along with facilitation has also resulted in the improved uptake of a cognitive behavioral therapy intervention by school professionals compared with extended training (coaching; Smith et al, 2022). The tailored InPACT intervention was disseminated to teachers in one additional low-resource school (80% FRL).…”

Individual and organizational factors as predictors of early evidence-based practice adoption in Michigan high schools: Baseline data from an implementation trial

“…CBT is one mental health EBP with well-established evidence showing positive effects on youth with anxiety and depression ( Haugland et al, 2020 ; Higa-McMillan et al, 2016 ; Spirito et al, 2011 ), across racial groups ( Ginsburg & Drake, 2002 ; Rosselló & Bernal, 1999 ) and through modular or components-based programs ( Becker et al, 2012 ; Chiu et al, 2013 ). Studies have shown that CBT can be effectively delivered by SPs in school settings ( Ginsburg et al, 2020 ; Koschmann et al, 2019 ; Masia Warner et al, 2016 ; Sanchez et al, 2018 ).…”

Correction: Primary aim results of a clustered SMART for developing a school-level, adaptive implementation strategy to support CBT delivery at high schools in Michigan

“…Following publication of the original article [ 1 ], it was reported that an incorrect version of Additional file 1 was published. The correct files are included in this Correction and the original article [ 1 ] has been updated.…”