Marginal Cost Analysis of Two Train-the-Trainer Models for Implementing SafeCare®

In adopting evidence-based practices (EBP), program administrators most frequently focus on program effectiveness. But there is growing recognition of the importance of program cost and of economic analysis for allocating scarce resources for prevention and intervention programs.1 Economic analysis includes the assessment of programmatic costs using a micro-costing approach (precise individual resource valuation) to value the resources required to implement programmatic processes and activities so that programs can be compared to each other.2–5 Differences in program cost are typically driven by differences in program length, staff requirements to implement the program and materials. However, another key source of program cost is the implementation strategy. Program administrators must consider the costs to adopt or implement a program. Translation or implementation science focuses on the processes by which EBP are implemented. Less rigorous implementation procedures often fail to yield implementation with fidelity, which is needed to achieve program outcomes.6 More rigorous strategies are more expensive, but there is evidence that they are needed to achieve implementation with fidelity.7,8 Thus, the consideration of implementation costs is an important area of study. That is, just as intervention scientists have studied how much intervention is needed for behavior change, implementation scientists must study how much implementation is necessary to achieve fidelity. To date, however, few studies have considered costs in implementation research,9 and fewer still have specifically focused on the costs of implementing EBP in the field of child maltreatment (CM) prevention.10 To our knowledge there are no studies that have calculated implementation costs for variants on a model and then related those costs to implementation outcomes. This paper presents a calculation of marginal implementation costs for 2 variants of a training program for the SafeCare® model, an evidence-based parenting model for child maltreatment prevention. SafeCare® has been disseminated to child welfare systems across 20 U.S. states. The SafeCare® dissemination model includes a “train-the-trainer” component in which staff external to the purveyor (the National SafeCare® Training and Research Center [NSTRC]) are trained over time to train local staff. The training of trainers is notoriously difficult and often fails because of the lack of follow-up support.11 In the study reported here, we trained trainers under 2 different models to examine the impact of trainee and client outcomes. A first step in understanding the impact of the 2 models is to calculate marginal cost differences in the 2 training models. The 2 training models differed primarily in their provision of support to new trainers following completion of the train-the-trainer program. Trainers were randomly assigned into 1 of 2 models for training, standard or enhanced. In the “standard” approach, the model includes a 5-day workshop with skill demonstration and proficiency improvement through role-playing activities and live training sessions. The model includes some ongoing support from NSTRC training staff, and in turn, trainers provide some support to the providers they train. The second model, the “enhanced” approach, provided extensive ongoing consultation from NSTRC training staff for 6 months upon completion of the trainer training workshop. In this paper, we present data collected to determine marginal cost differences between the 2 models. Although we do not present data on implementation and client outcomes, this paper serves as an example of how data collection on this topic can be accomplished and how marginal costs are computed.