High impact of implementation on school-based smoking prevention: the X:IT study—a cluster-randomized smoking prevention trial

Abstract

BackgroundImplementation fidelity describes how well an intervention is implemented in the real-world setting. Assessing implementation fidelity is essential in the understanding of intervention results. In most studies, implementation fidelity is measured insufficiently, though, not taking into account the complexity of the concept nor the intervention.The objective of the present study was to develop an overall quantitative measure of implementation fidelity, to examine the degree of implementation fidelity and the association of implementation and effect of a randomized school-based smoking prevention trial—the X:IT study.MethodsA cluster-randomized trial testing is a multi-component intervention to prevent smoking among adolescents in 94 Danish elementary schools (51 intervention, 43 control schools). Participants were grade 7 pupils (mean age 12.5 years). Data was collected by electronic questionnaires among pupils at baseline (n = 4161), the first follow-up (n = 3764), and the second follow-up (n = 3269) and among school coordinators at intervention schools at the first and second follow-up (50 and 39 coordinators).Intervention: The intervention included three components: (1) smoke-free school grounds, (2) smoke-free curriculum, and (3) parental involvement, contracts, and dialogues. Implementation fidelity was assessed by four domains: adherence, dose, quality of delivery, and participant responsiveness. These were combined into an overall school-wise implementation index. The association of implementation and smoking was examined by logistic regression analyses.ResultsOne fourth of the schools was characterized as high implementers of the program (all three components) at both first (12 schools, 24.0 %) and second follow-up (11 schools, 28.2 %). Implementation fidelity was strongly associated with smoking at the first and second follow-up, e.g., the odds for smoking at schools with high implementation both years were OR = 0.44 (95 % CI 0.32 to 0.68).ConclusionsUsing an overall measure based on several aspects of implementation fidelity, we showed a negative graded association between implementation and smoking. This study suggests that higher degrees of implementation will improve the effect of the X:IT intervention. Studying the association between implementation and effect is extremely important; only by doing so, we can distinguish the quality of the intervention from the success of the implementation.Trial registrationCurrent Controlled Trials ISRCTN77415416

Evaluation of the Tobacco-Use Prevention Education (TUPE) program in California

“…The literature suggests that school-based tobacco prevention programs can be effective in preventing the initiation of tobacco products if the programs are sufficiently intense and well implemented. [ 4 , 11 – 15 ] Therefore, if the program is well implemented, we would expect students would be less likely to use tobacco products. Our research shows that students at TUPE-funded schools are indeed less likely to use tobacco products than students at non-funded schools.…”

“…Success appears to depend on program content, intervention intensity, and program implementation. [ 12 – 15 ]…”

Cluster randomised controlled trial of an online intervention to prevent ecstasy and new psychoactive substance use among adolescents: final results and implications for implementation

“…The present findings should be interpreted in light of several limitations. First, our measure of implementation fidelity focused on only one dimension, intervention dose, 36 and we did not assess teacher-related factors, such as quality of delivery and adherence to programme content. However, since the Climate Schools programme is completed individually by students via the internet, these teacher-related factors are potentially less important for this study.…”

“… 39 40 Although several different elements of implementation have been proposed, in the context of school-based prevention key factors to consider are adherence to the intervention by teachers and/or facilitators, quality of delivery, dosage of the intervention and student engagement. 36 39 The internet-based nature of the Climate Schools programmes affords several advantages in terms of the degree of fidelity that can potentially be achieved. For example, the core content is preprogrammed online and completion is self-directed by students, thus delivery is not dependent on teacher training or skills, ensuring faithful delivery of the core programme components.…”

“… 43 Related to this is the ability of online interventions, such as Climate Schools, to track and collect objective dosage data in real-time rather than relying on teacher self-report. 44 Although previous studies have examined the impact of implementation of school-based substance use prevention programmes on student outcomes, 36 45 the influence of implementation quality of online drug education prevention programmes has not yet been explored. Taking this all into account, the aims of the current paper are twofold: to evaluate the effectiveness of the Climate Schools: Ecstasy and Emerging Drugs module over a 2-year period, and examine the impact of intervention dose (number of lessons received by students) on outcomes.…”