# Presentation: 344253

## SAMHSA/CSAP Prevention Fellowship TrainingImplementation Workshop: SPF Step 4 Providence, Rhode IslandMarch 19–20, 2007Day 1

## Section I: Introduction of Participants

- Answer one of the following questions and complete the analogy:
- Being a part of the Fellowship program is like?
- Working with the Strategic Prevention Framework is like?
- Working in the field of Prevention is like?

## Learning Objectives

- At the end of this training workshop, participants will be able to:
- List at least 4 criteria that should be considered when selecting strategies
- List the steps in implementation
- Identify the role of cultural competency within each of the implementation steps
- Describe the external and internal influences that can affect successful implementation
- Understand the concepts of fidelity and adaptation and identify cultural considerations in adapting evidence-based practices
- Explain why implementation is critical to program success and how it relates to strategy selection and outcomes

## AgendaDay 1

- Welcome and Introductions
- Fellows Demonstrate the SPF Benchmarks for Steps 1–3
- Selecting Strategies
- Lunch
- Overview of Step 4: Implementation and the SPF
- The Phases of Implementation

## Spirit of the Day

**CSAP and NECAPT**
- Maximum interaction and learning opportunities for participants
- Opportunity to learn in the context of your own work experience and Fellowship experience
- Does not repeat past training content but builds upon what participants have learned

## Spirit of the Day

- Fellowship Participants:
- What do you need from the training, trainers, and one other to get the most from the next two days of training?

## Section II:Fellows Demonstrate the SPF Benchmarks:An Interactive Activity 

## Activity Purpose

- 	Provide Fellowship participants with the opportunity to discuss the SPF steps in relation to their Fellowship experience

## Considerations in Developing the Activity

- Each Fellow has a unique fellowship program and activities that he or she is performing.
- Fellows are in:
- States (State Incentive Grants and States with SEOW Grants)
- Community settings
- National organizations
- There is a wide spectrum of experiences that Fellows have working with the SPF in their fellowships.

## Activity Instructions

- Around the room you will see the 5 steps with examples of work that happens in that step at the State and community level.
- Select a step that you feel reflects your current work or the work of the State community coalition or national organization.
- If there is more than 1, select the step that most interests you. If you can’t find a step that reflects your work,** **select a step that you are interested in.

## SPF Step Questions

- Introduce yourself and identify what state, community, or national organization you are working with and why you chose this step.
- Group questions
- What successes and challenges have you observed in this step?
- What advice would you give regarding this step to a State or community that was just beginning?
- What questions do you have regarding this step?

## Identifying and Selecting Evidence-Based Interventions (EBIs)

**Notes:**
At this point, you have assessed your needs and resources, know what capacities you have and what resources need to be increased, now you are ready to move into planning and selecting effective strategies.  How do you know what to do?  There are many programs out there that have shown to be effective with various groups of youth, parents, and communities.  Check out the Samhsa website for this information.  Remember CSAP also knows that there are many strategies that are “home grown” and occur in various communities around the country.  They are trying to cultivate and disseminate these strategies through the process called, NREPP.  (brief description)

Large group:  Test your knowledge question:  How do strategies fit into the SPF logic model?  What are they linked to?  Why?

## Reducing Alcohol-Related Youth Traffic Fatalities

**among 15–24 year olds**

**Low or discount PRICING of alcohol**

**Easy RETAIL ACCESS to alcohol for youth**

**Easy SOCIAL ACCESS to alcohol**

**Media advocacy to increase community concern about underage drinking**

**Restrictions on alcohol advertising in youth markets**

**SOCIAL NORMS accepting and/or encouraging  youth drinking**

**PROMOTION of alcohol use (advertising, movies, music, etc.)**

**Low ENFORCEMENT of alcohol laws **

**Young Adult DRINKING AND DRIVING**

**Social event monitoring and enforcement**

**Bans on alcohol price  promotions and happy hours **

**Enforce underage retail sales laws**

**Risk and Protective Factors and Other Underlying Conditions**

**Strategies**
**(Examples)**

**Substance-Related Consequences**

**Substance**
**Use**
**(Consumption)**

**Reducing Alcohol-Related Youth Traffic Fatalities**

**Low PERCEIVED RISK of alcohol use **

**Underage  BINGE DRINKING**

**Young Adult****BINGE DRINKING**

**Underage****DRINKING AND DRIVING**

**Notes:**
Often time we start w/ strategies- but need to start w/ problem and working through R&P to get to the strategies. 

Variables are the opportunity for intervention.

## Strategy Match

**High-risk drinking        18–25 year olds**

**Low-price alcohol specials in bars**
**Servers not checking IDs**

**Peer education **
**Mentoring program**

**Strategy Match**

**Notes:**
Often the tendency is to start w/ strategies and what we have done and what we have skills to do.  And this is clearly a strategy that does not match...

If you are trying to impact “intervening variable” and ultimately the “consequence” then strategies must match
These strategies do not match

Ask what intervening variables may the strategies shown impact?

## Strategy Match

**Responsible server education **

**Strategy Match**

**Low-price alcohol specials in bars**
**Servers not checking IDs**

**Consequence and consumption: **
**High-risk drinking        18–25 year olds**

**Notes:**
These strategies are matched with the risk factors/ contributing factors associated with retail access of alcohol.  Enactment of these environmental strategies will very likely impact the risk factors and in conjunction with other complementary strategies – drive down high risk drinking.

## Selecting Best-Fit Prevention Interventions

**Select Specific **
**Programs,**
**Practices, **
**& Policies**

**Ensure **
**Effectiveness**

**Identify**
**Types of **
**Strategies**

**Best-Fit**
**Prevention**
**Interventions**

**Demonstrate Conceptual Fit**

**Demonstrate Evidence of Effectiveness**

**Demonstrate Practical Fit**

**Relevant?**

**Practical?**

**Effective?**

**Notes:**
Often communities need to use 
Process for narrowing down to find the best fit intervention.

## A “Good Conceptual Fit” intervention should:
Fit into community logic model
Drive positive outcomes in identified substance abuse problems
Address the community’s intervening variables
Be founded on evidence-based principles for target population  
Target multiple opportunities for intervention

- Fit into community logic model
- Drive positive outcomes in identified substance abuse problems
- Address the community’s intervening variables
- Be founded on evidence-based principles for target population
- Target multiple opportunities for intervention

**Conceptual Fit**

**Notes:**
Ask yourself, do I have good reason to believe that this “type of strategy” will address that risk and protective factor?

The question to ask yourself is “Is the type of strategy relevant to the logic model, intervening variables”?

## Types of Strategies

- Policy
- Enforcement
- Communication
- Collaboration
- Education
- Alternatives
- Early Intervention

**Notes:**
Define strategies
Provide Handout w/ definitions of strategies

Small group activity – In groups of 2 or 3, Use the NM logic Model pick 1 risk factor and decide on 3 types of strategies that may best fit conceptually fit that factor

Under age or Illicit drug

## Sample Strategies in Underage Drinking Logic Model

**Consequence**
**and Consumption **
**Patterns**

**Intervening **
**Variables**

- Underage
- Drinking

**Access/ **
**Availability**

**Strategies**

_**Enforcement**_
**Increase Enforcement**
**Of existing laws**

_**Communication**_
**Media campaign regarding**
**Describing penalties for hosting**
**or furnishing alcohol**
**Social host liability**

_**Collaboration/Communications**_
**Work with media to publicize **
**incidents of furnishers/hosts **
**being **
**caught & prosecuted**

**Notes:**
*Access/ Availability – social and retail

## Sample Strategies (continued)

**Consequence**
**and Consumption **
**Patterns**

**Intervening **
**Variables**

- Underage
- Drinking

**Access/ **
**Availability**

**Strategies**

_**Policy:**_** **
**Alcohol tax increase to **
**raise overall price of alcohol**

_**Education:**_** **
**Merchant education, clerk **
**training on ID checks**

_**Collaboration:**_
**Partner with Retailers**

_**Enforcement **_
**Compliance Checks to ensure **
**compliance with Minimum **
**	****	****	****Drinking Legal Age (MDLA**) *	**	**	*

**Notes:**
*Access/ Availability – social and retail

## Ecological Model

**Notes:**
Target multiple domains or contexts across the lifespan

Consider questions of reach when selecting strategies:
How many people will your interventions impact?
Which sectors of the community will be impacted by your efforts?
What dosage of the interventions will target audience experience? 

## Practical Fit for Community 

- Feasible given a community’s resources, capacities, and readiness to act
- Add to or reinforce prevention strategies in the community—synergism and layering
- Consider community climate
- Meet cultural needs of target population
- Sustainable in community
- Evaluability

**Notes:**
Next criteria is practical fit – Can your organization do this in your community?

## Practical Fit Activity

- In small groups, assess how well the strategy practically fits your assigned community coalition.
- Does your coalition have the staff and funding needed?
- Do you have the necessary community contacts needed (police, leaders, etc.)?
- Will the community support this strategy?
- Does this strategy reflect your community’s culture?
- Could this strategy be sustained?
- Could this strategy be easily evaluated?

**Notes:**

Handout Coalition – select 1 intervening variables
Given that u are in this community and situation – now which is the best fit given for your community

Groups will answer the discussion questions to determine how well that strategy would fit in their community.

Ask groups to briefly report out on how practical the strategy could be for their community

Share example of NECAPT feasibility tool to assess fit

## Effectiveness	

- Strength of evidence
- Finding Evidence-Based Interventions
- Creating a Comprehensive Approach

## Paradigm Shift

- From picking off lists to thinking critically about needs
- From categorical labels to ratings along a continuum
- From relying on strength of evidence alone to assessing the relative importance of strength of evidence in a broader context
- From stand-alone intervention selections to comprehensive community plans

**Notes:**
CSAP process to expand the field of potential strategies
Expert Workgroup on Evidence-Based Programming
Convene nationally recognized prevention researchers—diverse theoretical backgrounds and perspectives
Develop recommendations and guidelines for prevention planners—SPF SIG Program
Need broad array of evidence-based interventions, and
Flexibility to choose options that fit community circumstances

## Evidence-Based InterventionsStrength of Evidence

- The strength of evidence of a tested intervention will fall somewhere along a continuum from weak to strong
- The strength of evidence is assessed using scientific standards and criteria for applying these standards

*The nature of evidence is continuous*

## Strength of Evidence Components

- Rigor of the study
- Rigor and appropriateness of the methods used to collect and analyze the data
- The extent to which a finding can be generalized to similar populations and similar settings.

**Notes:**
Rigor of the study/
Example using experimental and than having a control as well. Having a control group would be considered of higher rigor, depending on how the experimental was conducted at both sites 

Rigor and appropriateness of the methods used to collect and analyze the data
I might not use a written survey instrument with an illiterate audience. 
Issues of language, culture, age

The extent to which finding can be generalized to similar populations and similar settings. 

## Resource Mechanism for Evidence-Based Intervention

- Included on federal lists or registries of evidence-based interventions;
- Reported (with positive effects) in peer-reviewed journals; and
- Documented evidence of effectiveness based on guidelines developed by SAMHSA/CSAP

**Notes:**
Workgroup decided on guidelines to assist in process of identifying strategies (not a new list) ...

## Resource Mechanism for Evidence-Based Intervention (cont’d.)

- Guidelines for Documenting Effectiveness:
- Based in solid theory validated by research;
- Supported by a documented body of knowledge generated from similar or related effective intervention; and
- Judged by informed experts to be effective.

**Notes:**
Informed experts could include state level group OR key community prevention leaders and/ or elders, or other respected leaders within indigenous cultures.

## How Do You Find Evidence-Based Interventions?

- Federal registries
- CAPT resources
- Experts in the field (NIAAA, NIDA)
- Research** **

**Notes:**

This info will also be a handout

## Summary of Things to Consider

- Conceptual fit
- Practical fit
- Effectiveness

**Notes:**
There are lots of things to consider here is a summary.

## Section IV:Energizer

## Fun Facts of Rhode Island:   True or False?

- Select teammates
- Name your team
- As a group, determine if the statements provided about Rhode Island are true or false
- The group with the most right answers wins

## Section V:Overview of the SPF Step 4: Implementation 

## Implementation Involves:

- Taking action guided by the Strategic Plan created in Step 3 (Planning) of the SPF

##  Implementation Slogans

- “Just do it” Nike
- “Make it so” Captain John Luke Piccard
- “Taking you forward” Ericsson
- “Jump in” Xbox 360
- “Performance Defined, Results Delivered” Synergy
- “Moving forward” Toyota
- “Let's go” Maruti Alto, India 2005

## Overview of Implementation StepState and Community

## SPF Step 4 Requirements Implement infrastructure development activities

- State level
- Build capacity to provide the infrastructure and other necessary support for State and local level SPF process
- TA and training system targeted at building capacity at the local level
- Development of products and tools that can assist the SPF process locally
- Contract development and monitoring system
- Monitoring and evaluation system

## SPF Step 4 RequirementsImplement evidence-based prevention strategies and infrastructure development activities

- Community Level
- Use the findings of needs assessments to guide selection and implementation of evidence-based policies, programs, and practices
- Strategies must be evidence-based
- Development of an implementation plan

## State and Community Implementation

**State Level****Implementation**

**Assessment **

**Mobilizing**
**Capacity**

**State and Community Implementation**

**Planning**

**Implement**

**Evaluate**

***Implement infrastructure development activities******state and local level***

**Community Level**

***Implement evidence-based prevention strategies and infrastructure development activities***

## State Activities That SupportSPF Process at the Local Level

- Generic logic model
- Literature search verifying risk and protective and underlying conditions
- Community profiles with data available at the State, regional, and local level
- Identification of data indicators for risk and protective factors, potential sources of data, and gaps in data
- Trainings and technical assistance tools for assisting local grantees

## Cultural Competency Considerationsfor Step 4:  Implementation

- Is the target population involved in the design of interventions?
- Is your intervention responsive to the population you have targeted and how do you know?
- Does/do the implementing organization(s) understand the shared values, attitudes, and beliefs of the community or population targeted?
- Does/do the organization(s) have the resources to deliver culturally appropriate strategies?
- Is information shared in a manner that is appropriate and understandable?

## Section VI:Phases of Implementation

## Opening Activity

- As a group, you will be given an ordinary daily task.
- As a group, brainstorm all of the steps in completing the task.
- You must reach consensus as a group regarding the steps and their order.
- Place your results on a flipchart.

**Notes:**
Looking at the list we can notice that not all of these are in the same time line in the project...some are towards the beginning some in the middle and some toward he end. It can be helpful when we are thinking of implementation that we break into three phases to assist us in thinking it through and planning for implementation successfully 

## Overview of Phases 

## The Phases of Implementation

**Pre-Implementation**** **
- Characteristics of strategies
- Organizational characteristics
- Environment
- Communication issues

- CDC, 1997

**Notes:**
Pre-implementation consists of four key components: characteristics of the innovation, organizational characteristics, the environment, and communication issues.
Characteristics of the Innovation
Characteristics of the innovation can affect whether and how rapidly adoption occurs. These characteristics include the innovation’s relative advantage, compatibility, complexity, flexibility, reversibility, risk, and cost efficiency.
Organizational Characteristics
Organizational characteristics often influence whether an innovation is adopted. This includes: the organization’s size, level of commitment and support from top management and workers for the innovation, decentralization, complexity, and degree of formalization.
Environment
Environmental characteristics include: public opinion, outside forces, and federal agencies. Public opinion around an issue can influence the extent to which organizations perceive a need to adopt an innovation. Outside forces can hinder the actions of health and social service agencies. Federal agencies can also encourage the adoption of innovations by disseminating information or providing change agents to support the adoption decision.
Communication Issues
The way people communicate ideas about the innovation and how decisions are made within organizations are an important component in the pre-implementation phase. Clear communication is critical in this process. Information about the intervention must be “translated” into a format that is understandable and accessible to potential users.
The type of communication and the nature of the decision making are also factors to consider. Informal communication might be more persuasive than formal communication. Research indicates that group decision making is more likely to lead to adoption than decision making by individuals.
The use of an opinion leader or linking agent can enhance the effectiveness of the communication factors discussed above.

## Pre-ImplementationThe Environment

*Smithtown, USA*
- Wanted to implement a zero-tolerance policy
- Did not have buy-in from city officials, police, or community members
- Did not understand community norms around underage drinking

*Jonestown, USA*
- Wanted to implement responsible beverage service (RBS) trainings
- Spent 1 year getting buy-in from liquor license holders in the community
- Found key leaders to talk about the importance of RBS

## Cultural Competency Considerations

- Pre-Implementation
- Is the strategy culturally appropriate and responsive?
- Will the strategy be delivered in a culturally appropriate manner?

## The Phases of Implementation

- Implementation
- Mobilizing support
- Training
- Balancing fidelity and tailoring to fit local circumstances
- Process evaluation

## ImplementationTraining and Process Evaluation

*Smithtown, USA*
- Implementing LifeSkills in high school setting
- No one working with staff to make sure implementing the program correctly
- Process evaluation found that 80% of teachers are changing the curriculum

*Jonestown, USA*
- Implementing LifeSkills in High School Setting
- Built-in staff coaching throughout the process
- Process evaluation found that less than 10% of teachers are changing the curriculum

## The Phases of Implementation

- Maintenance
- Technical assistance
- Administrative support
- Cost-effectiveness over time
- Evaluation and feedback

## MaintenanceEvaluation and Feedback

*Smithtown, USA*
- Decided to translate the parenting program, Guiding Good Choices, into Portuguese (high school had a growing number of recent Brazilian immigrants and parents spoke very little English)
- Evaluation showed very little change in parents’ attitudes and knowledge
- Found that curriculum was translated incorrectly and component videos were still only in English version

*Jonestown, USA*
- Latino parenting program targeting a bilingual audience (English and Spanish)
- 85% of parents successfully participated in an English or Spanish language program
- In process evaluation found a subset of parents who were illiterate in both languages

## Cultural Competency Considerationsfor Step 4:  Implementation

- Is the target population involved in the design of interventions?
- Is your intervention responsive to the population you have targeted and how do you know?
- Does/do the implementing organization(s) understand the shared values, attitudes, and beliefs of the community or population targeted?
- Does/do the organization(s) have the resources to deliver culturally competent strategies?
- Is information shared in a manner that is appropriate and understandable?
- Is the delivery of technical assistance and training culturally appropriate and responsive?

## Large Group Question

- Looking at the previous slide, for each question presented, label the implementation phase in which the question would occur.

## Getting to Know the Implementation Phases: A Case Study

## Small-Group ActivityInstructions

- Your group is reviewing applications from local communities that are trying to reduce Motor Vehicle crashes among 15–24 year olds.
- You are given information on the town of Lincoln’s planning process and the strategy it will be implementing.
- Your group will be assigned 1 of the 3 phases of implementation:
- Pre-Implementation, Implementation, or Maintenance
- As  a group, using the information in the case and the Phases of Implementation handout, answer the questions that pertain to your phase of Implementation.
- Select someone to report out.

## Town of Lincoln

- Lincoln substance abuse coalition is 4 years old
- Selected goal of reducing alcohol-related traffic fatalities among 15–24 year olds
- Selected risk factors of low enforcement
- Selected 2 strategies include sobriety checkpoints and media campaign

## Lincoln’s Logic Model

**among 15–24 year olds**

**Media campaigns tied to checkpoints**

**Low ENFORCEMENT of alcohol laws **

**Young Adult DRINKING AND DRIVING**

**Enforcement of drinking and driving laws **
**Sobriety checkpoints**

**Risk and Protective Factors**

**Strategies**
**(Examples)**

**Substance-Related Consequences**

**Substance**
**Use**
**(Consumption)**

**Lincoln’s ****Logic Model**
**Reducing Alcohol-Related Youth Traffic Fatalities**

**Underage****DRINKING AND DRIVING**

## Pre-Implementation

- Are there characteristics of the strategies proposed by the Lincoln coalition that might affect whether and how rapidly implementation will occur?
- What about the Lincoln coalition will either positively or negatively affect the implementation of enforcement and media campaign strategies?
- Are there any characteristics of the community of Lincoln that will positively or negatively affect the implementation of enforcement and media campaigns strategies?

## Implementation 

- Do the activities that the Lincoln coalition has proposed to mobilize support for the enforcement and media strategies seem adequate?
- In what ways is the Lincoln coalition preparing key stakeholders to implement programming?
- In what ways can/should the coalition tailor enforcement and media strategies to fit the local circumstances?
- How will Lincoln know that it has successfully implemented its strategies? More specifically, what process measures might it use?

## Maintenance

- What type of technical assistance do you think the Lincoln coalition might need to ensure continued success of its strategies?
- What type of personnel might be needed to sustain these efforts over time?
- What potential process data might Lincoln collect to monitor changes to its strategies?
- What potential outcome data might Lincoln collect to demonstrate that these strategies were successful?
- How would Lincoln demonstrate that its strategies are economically feasible?

## 					Questions 					     and
					Evaluation 					    Forms

**	****	****	****	****	****Evaluation ****	****	****	****	****	****    Forms**