Link for Schools: an Evaluation of a Tiered Staff Training Program and Student Intervention to Prevent Violence
Condition: Risk Reduction Behavior
Study type: Interventional

Summary: 
      The University of Iowa in collaboration with the Cedar Rapids Community School District
      (CRCSD) conducted an effectiveness study to test a theory-based system, called Link, that
      trained school staff to provide a sustainable infrastructure of support for youth at-risk of
      violence. Our purpose was to prevent and intervene in violence that impacts students, and to
      adopt cost-effective school-based violence prevention strategies.

      The research team conducted a randomized intervention trial with three "clusters" of within
      the CRCSD using the procedures described in the following paragraph. Each cluster consisted
      of a middle school and three "feeder" elementary schools. Implementation of the program began
      in Fall 2017 at Cluster 1, Fall 2018 at Cluster 2, and Cluster 3 remained a control site and
      received no intervention.

      Program Implementation, by Cluster:

      A series of videos were produced by the University of Iowa team in conjunction with the
      CRCSD, and were offered as a training opportunity to school staff. The series of video
      trainings include: Trauma Informed Care (TIC) video to be viewed by all staff; and a Link
      Program training video for select staff.

      TIC video instructions was required of all staff during a workshop session. Participants were
      invited to complete a post-training evaluation survey following the viewing of the TIC video,
      for research.

      Concurrent with the delivery of the Trauma Informed Care video training, select staff were
      identified by the CRCSD research team to become Link interventionists, by participating in
      specialized training of the Link system using the Link Program video and in-person trainings.
      These interventionists had a dual role as a study participant and as a member of the research
      team. These interventionists were provided 4 in-person trainings throughout the school year
      that included training in child assent procedures, and Link Program training. These
      interventionists were invited to complete pre/post evaluation surveys at each training
      session, for research.

      Targeted Research Intervention:

      Following the Link Program Training, the CRCSD research team randomly assigned a case load of
      students to the Link interventionists with whom they used the Link Program skills. Following
      each student encounter, the interventionist completed a Link Case Management Tool for process
      evaluation. Link interventionists were also invited to complete a pre-evaluation survey prior
      to Link Program training, and post-evaluation surveys following training sessions.

      Data collected for the targeted student intervention included: primary data in the form of a
      Link Case Management Tool completed by a Link interventionist following each student
      encounter; secondary data in the form of existing school administrative data sources (i.e.,
      enrollment and office referrals).
    

Detailed description: 
      Program implementation and the targeted student intervention were implemented using a
      staggered approach.

      Cluster 1 began study procedure in 2017, and the process is outlined below.

      Program Implementation:

      Trauma Informed Care Training: Following consent, staff participants viewed a Trauma Informed
      Care (TIC) training video (TIC video available for review at:
      https://publichealth.uicapture.uiowa.edu/Panopto/Pages/Sessions/List.aspx?folderID=e4d017e6-6
      133-4d0b-819d-495f72c74284) that was delivered at a staff in-service session organized by the
      school district. All participants were invited to complete an anonymous "TIC post-training
      evaluation" survey immediately following TIC video viewing; those participating in in-person
      training will complete a paper survey.The survey took approximately 5-10 minutes to complete.

      Specialized Link Interventionist Training- Session 1: Identified Link Interventionists were
      provided training by UI IRB and the UI Research team, for their role as research team members
      for purposes of assenting students participants, and to be trained in study protocol. The
      research team presented a group presentation about the research study, and following consent,
      participants were invited to complete an anonymous "Link_pre-program evaluation" survey. The
      survey took approximately 5-10 minutes to complete.

      Session 2: The Link Program training session consisted of a combination of Link video
      training (Link training video available for viewing at:
      https://publichealth.uicapture.uiowa.edu/Panopto/Pages/Sessions/List.aspx?folderID=e4d017e6-6
      133-4d0b-819d-495f72c74284) and in-person training conducted by the UI research team.
      Participants were invited to complete an anonymous "Link_post training evaluation_initial"
      survey at the end of the session. The survey took approximately 5-10 minutes to complete.
      This training session lasted approximately 2 hours and occurred during an in-service training
      session scheduled by the school district. Following this training session, participants were
      randomly assigned a case load of students with which they used the Link Program skills.
      Following each student encounter, the interventionist completed a "Link Case Management Tool"
      for process evaluation. This tool took approximately 5-10 minutes to complete.

      Session 3: Approximately 6 weeks following the initial training session, a follow-up training
      session was conducted. This training session consisted of video training and in-person
      training. Additional video training consisted of reviewing specific student scenario videos
      and other additional videos developed by the research team (7 scenarios and "Tools for You"
      are available for review at:
      https://publichealth.uicapture.uiowa.edu/Panopto/Pages/Sessions/List.aspx?folderID=e4d017e6-6
      133-4d0b-819d-495f72c74284). Participants were invited to complete an anonymous "Link_post
      training evaluation_follow up" survey at the end of the session. The survey took
      approximately 5-10 minutes to complete. This training session will last approximately 2 hours
      and occurred during an in-service training session scheduled by the school district.

      Session 4: At the end of the school year, a final training session was conducted. This
      training session consisted of a de-briefing discussion about challenges, successes, and
      future implementation. Participants were invited to complete an anonymous "Link_post program
      evaluation" survey at the end of the session. The survey took approximately 5-10 minutes to
      complete. This training session lasted approximately 1 hour and occurred during an in-service
      training session scheduled by the school district. Due to school cancellation because of the
      COVID-19 response, this training session was conducted remotely via zoom during the final
      year of the study; participants were able to join the training session using a laptop or
      phone. The research team provided a zoom link to the school district project manager, who
      emailed a meeting invitation to all program interventionists/participants. Following the
      training session, a survey link to the evaluation survey was emailed to participants via
      REDCap's automated survey function and completed electronically. Data was stored in a REDCap
      database maintained by the University of Iowa.

      These Link interventionist training sessions were audio recorded for training content
      analysis.

      Targeted Student Intervention The school district research team maintained a list of students
      in Clusters 1, 2, and 3 schools whose parents have provided consent for participation, and
      met eligibility criteria. Students were then assigned to randomization arms by the research
      team.

      Immediate intervention group: Following assent by the Link Interventionist, the student had a
      conversation with the interventionist in which the interventionist used specific
      communication skills they learned through their training described above. The interventionist
      may or may not have used specific tools they were exposed to during the training sessions
      (stress screener, etc.) and referred the child to additional resources as necessary. The
      student subject was invited to meet with the interventionist several times (up to 2 times per
      week) during the remainder of the school year. These encounters were approximately 10-30
      minutes in length, and occurred during the school day in a private location determined by the
      interventionist and the school district research team. The student was referred to additional
      resources, as necessary, and as a result of the meetings.

      Wait-list control: These students were approached for intervention the semester following the
      implementation of the intervention, and interventionists used the same procedures described
      for the immediate intervention group. While on the wait-list, students assigned to this
      intervention arm received the same standard services offered by the school district to
      students at control group schools. This multi-level wait-list design (both at Cluster and
      student level) is ideal for evaluating the effectiveness of a program that is realistically
      rolled out over time. The wait-list also allows for comparisons between students who receive
      support vs. those who do not, and comparisons of students in a mature program vs. newly
      implemented program. The wait-list is an ethical approach used in other intervention
      evaluation studies of mental health treatment programs for at-risk children exposed to
      violence. Due to school cancellation due to COVID-19 response, interventionists contacted
      parents via phone (numbers are available to school staff in PowerSchool) to check-in with the
      family and student. During this phone call, the interventionists assessed whether the student
      was interested in continuing the intervention electronically (phone or web meeting).
      Depending on the students' preference, the interventionist then conducted any future session
      via phone (using the phone number listed in PowerSchool) or web meeting (an email invitation
      was sent to the student participant's school-based email address from the interventionist).

      Cluster 2: Same procedures as Cluster 1, but commencing the following school year

      Cluster 3: Control group, did not receive any training or intervention. During registration
      at the beginning of the school year, parents were provided a letter via PowerSchool/school
      district website notifying them that the district will be providing de-identified student
      data to University of Iowa researchers for research purposes. If parents objected, they were
      instructed to contact a school district official (listed on the letter), and their student's
      data would be removed from the data set shared with investigators.

      For all clusters, the school district research team provided individual-level data
      (identified with a student ID number only), sorted by intervention arm, about these students
      to the UI research team for analysis. This data was in the form of administrative student
      records (i.e., enrollment, office referrals). The UI research team was not provided a key
      code for these data.
    

Intervention name(s): Link Intervention
Intervention type(s): Behavioral
Intervention description(s): Eligible students met with staff trained in specialize intervention skills. Staff met with students multiple times per month, for approximately 10-30 minutes. During these sessions, staff had conversations with students, using intervention communication skills, assessed student stress, and implemented strategies for behavior change. Details of the sessions were recorded in a case management tool. Students were referred to additional resources, as necessary, and these referrals were also recorded. Rates of student office referrals were assessed over time.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This study is a two-level randomized intervention trial of students from 12 schools in three clusters.
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: School violence prevention