Reopening Schools Safely and Educating Youth (ROSSEY) Study: Protocol for a Community-based, Cluster Randomized Controlled Trial

Abstract

Introduction.

ROSSEY is a community–academic partnership aiming to develop and test a COVID-19 risk communication intervention for elementary school students and families in Yakima County, Washington. We describe the ROSSEY study protocol that will be implemented in the Yakima School District.

Methods.

Aim 1 is to identify the community’s social, ethical, and behavioral needs and resources for students to return to school and maintain onsite learning. We will conduct semi-structured interviews with students and school employees and focus groups with parents. Aim 2 is to evaluate the effectiveness of risk communication on students’ school attendance. We will conduct a cluster randomized control trial. We will enroll 14 Yakima School District elementary schools with 900 student participants and randomize the schools into the COVID-19 risk communication intervention or control group. Aim 3 will assess implementation of the risk communication intervention and schools’ COVID-19 mitigation strategies. We will use the RE-AIM framework to guide this work, which will entail conducting semi-structured interviews with students and school employees and focus groups with parents.

Discussion.

Implementation of science-based risk communication can educate the community on the benefits and safety of COVID-19 testing and vaccination. Risk communication may also inform families about the role of COVID-19 testing and vaccines as part of mitigation strategies to allow for safe in-person learning. Schools have extraordinary influence to promote children’s health through policy and practice change. Study findings will provide evidence to facilitate policy decisions and best practices at schools that facilitate adoption of COVID-19 risk communication.

Trial registration.

ClinicalTrials.gov NCT04859699. Registered on April 26, 2021.

1. BACKGROUND

The COVID-19 pandemic magnified health inequities faced by vulnerable communities in the U.S.¹ While the pandemic is now under better control, rural agricultural communities in Washington state’s Yakima County had the highest SARS-CoV-2 positivity and mortality rates in the state at the height of the pandemic.² Communities in Yakima County experienced disproportionately poor health outcomes from COVID-19, in part due to high rates of comorbidities, including cancer, diabetes, cardiovascular disease, obesity, and obesity-related diseases.^3,4 Negative experiences with social determinants of health (e.g., food and housing insecurity, poor healthcare access, unemployment) and limited community infrastructure and resources have been well documented before the pandemic and were amplified during the COVID-19 public health emergency in Washington state.⁴

The slow release of scientific information due to evolving public health knowledge on SARS-CoV-2, limited access to scientific expertise with concentration of academic and research centers in urban areas of the state, and politicization of the pandemic all likely fueled misinformation (i.e., information that is likely to create false beliefs⁵) and created a breeding ground for disinformation (i.e., misleading information that is deliberately intended to mislead⁵) in these communities.^6–8 Preventive measures (e.g., masking and vaccines) were affiliated with political statements, and concerns around the effectiveness of SARS-CoV-2 testing and vaccine hesitancy were widespread.^9,10 To turn the tide, consistent, science-based, accurate risk communication is needed to instill trust and confidence in SARS-CoV-2 testing and decrease vaccine hesitancy in rural communities.

ReOpening Schools Safely and Educating Youth (ROSSEY) is a community–academic partnership aiming to develop and test a culturally appropriate COVID-19 risk communication intervention for elementary school students and families in Yakima County. The outcomes are COVID-19 knowledge and prevention behaviors (e.g., masking, testing, vaccination), student school attendance, and families’ physical and mental well-being. In this paper, we report on the design and implementation of a cluster randomized controlled trial conducted in Yakima School District elementary schools to test the effectiveness of the risk communication intervention.

2. METHODS

2.1. Study design and specific aims

ROSSEY is funded by the National Institutes of Health’s Rapid Acceleration of Diagnostics—Underserved Populations (RADx-UP) Initiative. RADx-UP is a consortium of more than 125 research projects studying COVID-19 testing patterns in communities across the U.S., its territories, and Tribal Nations.¹¹ The goal of RADx-UP is to develop and implement COVID-19 testing programs for medically underserved or disenfranchised communities. Researchers collaborate with community partners to design and implement study protocols and collect data on study findings that will help community leaders and policy makers identify effective strategies for reducing disparities in COVID-19 testing and address other health needs in their communities. ROSSEY is designed to complement free COVID-19 testing services offered to families for their children at schools through the Yakima School District and Health Commons’ Learn to Return Program.¹² ROSSEY involves three specific research aims intended to help students return to school safely by providing free health education to families and their children:

• Aim 1. Identify rural Latino community’s social, ethical, and behavioral needs and resources for students to return to school and maintain onsite learning using qualitative assessments with school staff and administrators, parents and guardians, and students.

• Aim 2. Evaluate the effectiveness of risk communication on student attendance and participation in SARS-CoV-2 testing using a cluster randomized control trial with two arms: COVID-19 risk communication as the intervention and no intervention as the control.

• Aim 3. Assess implementation outcomes of the COVID-19 risk communication intervention and COVID-19 mitigation strategies with school staff and administrators, parents and guardians, and children guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework.¹³

2.2. Study setting and population

Yakima County, Washington has a population of over 257,000 and roughly 53% of residents are of Hispanic/Latino origin.¹⁴ Many Latino residents in Yakima County are employed in agricultural and food packing industries, along with some contracted seasonal workers within and outside of the U.S. who migrate during farming seasons. We will collaborate with the Yakima School District to recruit kindergarten through 5^th grade elementary school students and their parent or guardian into the research study. We will recruit elementary school students regardless of their participation in SARS-CoV-2 testing provided by the Yakima School District. This will allow us to evaluate the effect of the COVID-19 risk communication intervention on uptake of SARS-CoV-2 testing and other mitigation measures. The school district has around 16,000 students and 14 elementary schools. Most students (80%) identify as Hispanic/Latino, over half (55%) receive free or reduced-price lunch, and a little less than a third (31%) are learning English as a second language. The student to teacher ratio is approximately 18:1 (Washington state average is 17:1).¹⁵ The school district employs 21 certified school nurses, 10 health assistants, three classified nurses that provide one-on-one student support, two community health workers, two health and wellness administrators, and one office manager.

2.3. Community–Academic Partnership

This study builds on more than 10 years of partnership between researchers and a local community advisory board (CAB). The CAB has collaborated with the research team in areas of cancer prevention and control, obesity prevention among adults and children, and recently, COVID-19 prevention among families. The CAB consists of a diverse group of community members, including community-based organization representatives, school representatives, political figures, community health organization representatives, and community advocates. Consistent with Community-based Participatory Research (CBPR) principles,¹⁶ identification of the intervention, study design, and proposed evaluation and dissemination plans were conducted collaboratively between community and research partners. The study also includes three community members who are serving as community investigators.

2.4. Ethical approval and clinical trial registration

All study participants will provide informed consent according to institutional guidelines and requirements at the University of Washington. The study protocol has been approved by the University of Washington Institution Review Board (STUDY00013064) and registered at ClinicalTrials.gov.¹⁷

2.5. Aim 1: COVID-19 community needs assessment

Purpose.

We will identify rural Latino community’s social, ethical, and behavioral needs and resources for students to return to school and maintain onsite learning using qualitative assessments with school staff and administrators, parents, and students. These findings will inform the development and content of the COVID-19 risk communication intervention that will be delivered to elementary school children and their families in Aim 2.

2.5.1. Aim 1 recruitment and data collection methods

Qualitative semi-structured interviews will be conducted with school staff and administrators and students in Yakima County. Focus groups will be conducted in English and Spanish with parents and guardians who have students attending schools in Yakima County. All interviews and focus groups will be collected using a HIPAA-approved video conferencing software or by telephone. Interviews are expected to last 30–45 minutes and focus groups are expected to last 60–90 minutes. All interviews and focus groups will be audio-recorded and transcribed.

Interviews with school staff and administrators.

Semi-structured interviews will be held with 20 school staff and administrators, including superintendents, principals, teachers, and health professionals. Based on our prior study with the target population,¹⁸ we estimate that recruitment of 20 school staff and administrators will achieve data saturation. Recruitment will be conducted using the snowball effect, in which we ask a participant to provide the names and contact information of other school staff and administrators who may be interested in participating in the interview.¹⁹ The semi-structured interview will assess school districts’ readiness to have students return to school and maintain onsite learning and the COVID-19 mitigation strategies that schools will implement to minimize SARS-CoV-2 transmission.

Focus groups with parents.

Four focus groups (2 English, 2 Spanish) will be conducted to identify parents’ concerns over regularly testing children for COVID-19; concerns about children returning to school and resources needed; fears about children contracting COVID-19 and resources needed; and concerns regarding vaccination safety, acceptability, and uptake. Based on our prior study with the target population,²⁰ we estimate that conducting four focus groups will achieve data saturation. Parents who previously participated in a school-based study and provided consent for future contact will be mailed a letter and followed up by study staff through phone to assess their interest in participating in a focus group.

Interviews with students.

Once parents have agreed to participate in a focus group, we will assess parents’ interest and permission to enroll their children for a semi-structured interview. We will recruit 20 students. The sample size is based on our estimate on the number of parents who will agree for their child to participate in an interview. These interviews will cover concerns about regularly testing for COVID-19 and resources needed, ability to follow preventive measures at school and the onsite learning protocol, and fears about contracting COVID-19 and ways to mitigate concerns. Interview questions will be written in plain language to facilitate comprehension across students of different ages. Interviewers have extensive experience conducting interviews with children and will be able to tailor the wording of interview questions as needed to facilitate comprehension. Parents will also be invited to attend the interviews. All interviewers will receive additional training by senior researchers with expertise conducting qualitative research involving children. In addition, ROSSEY is registered at the University of Washington’s Youth Program Registration System.²¹ As part of this registration, study staff receive training on conducting research involving youth as study participants.

2.5.2. Aim 1 analysis plan

We will separately code transcripts for school employees, parents, and children using Dedoose version 9.0.62 (Los Angeles, CA). We will use an inductive, constant comparison approach to code transcripts.²² We will first create a set of a priori codes based on the semi-structured interview and focus group guides to ensure that information from the questions is retained during coding. Next, study staff trained in qualitative methods will conduct inductive coding to complement the deductive coding. Using an iterative process, five members of the research team will meet weekly to refine the codebooks by adding, removing, and revising codes and to compare new and existing data. Disagreement among coders will be reconciled via consensus.

We will identify themes from the codes by first reviewing the excerpts’ content within each code and identifying tentative themes. We will analyze the interrelationship across and within themes, which will result in a collection of candidate themes. In the final synthesis step, candidate themes will be reviewed in collaboration with the research team. The themes will be refined to ensure that excerpts are cogent, coherent, and that each final theme is conceptually distinct.

2.6. Aim 2: Cluster randomized controlled trial to test COVID-19 risk communication intervention

Purpose.

We will evaluate the effectiveness of risk communication on student attendance and participation in SARS-CoV-2 testing using a cluster randomized control trial (cRCT). Yakima School District elementary schools will be randomized to receive the intervention (risk communication) or serve as a control group. We will enroll 900 students from 14 elementary schools in the Yakima School District during the 2022–2023 school year.

2.6.1. Aim 2 Methods and experimental procedures

To prepare for the cRCT trial, we will conduct a pilot study in one school between April to June 2021 to pilot test study procedures with students in the Yakima School District. The cRCT trial will be implemented in 14 Yakima School District elementary schools during the 2022–2023 school year.

Recruitment and inclusion criteria.

Through school open houses, school websites, community information sessions, and radio advertisements on local stations, study staff will provide information about the ROSSEY study to parents or legal guardians (hence forth referred to as parents) of elementary school children. Eligibility to participate in the study is solely dependent on whether a child is a student enrolled in an elementary school in the Yakima School District during the 2022–2023 school year. Parents who express interest will share their contact information with study staff. After providing informed consent (parent) or assent (child) and prior to randomization, parents will complete the baseline survey. Multiple children from a single family may enroll in the study. If a parent has enrolled more than one child, we will select the child with the most recent birthday from the time of enrollment as the “index” child. The study schema is depicted in Figure 1.

Figure 1.

Aim 2 Study Schema

Randomization and experimental procedures.

Randomization will be conducted at the school-level (Figure 1). Schools will be randomized 1:1 (matched by school size and English language learners) to either the intervention or control group. Students and parents randomized to the intervention group will receive the COVID-19 risk communication intervention (see next section). Students and parents randomized to the control group will receive the same risk communication intervention at the end of the study as a delayed intervention.

2.6.2. COVID-19 risk communication intervention

Students randomized to the intervention group will receive three printed comic books with accompanying read-along videos once per month for three consecutive months (months two, three, and four of the study). Their parents will receive two health education videos focused on COVID-19 topics, including testing and vaccination (months three and four of the study). The intervention materials will be available in both English and Spanish. Students will receive the printed comic books by U.S. Postal Service mail. Their parents receive by U.S. Postal Service mail a password-protected link to access the comic book read-along videos for students and health education videos for parents.

The risk communication will highlight benefits and address barriers around preventive behaviors (e.g., participating in COVID-19 testing and vaccination) that we identified in Aim 1. The comic books will follow three main characters (siblings Hector, Mia, and Ava) and their experiences during the COVID-19 pandemic. The comic books will be narrated into videos for children with limited reading abilities and whose parents and/or siblings cannot read the comic books to them (i.e., “read-along” videos). Content for the risk communication materials is informed by the Health Belief Model and the Self Determination Theory.^23,24 The CAB will provide input on the messages, readability, and visuals and will approve the final version.

2.6.3. Aim 2 outcome assessment

Table 1 summarizes the outcome measures and timing of data collection. The primary outcome is school absenteeism, which will be collected about all children enrolled in the study. We will collect outcome assessment data using survey instruments that will be completed by parents only (we will ask parents to report on behalf of their child). Surveys will be available in both English and Spanish. Parents will be able to complete the baseline, month 5, and month 7 outcome assessment surveys online, on paper, or by phone with a study staff member. Parents will complete the weekly surveys during months 1–7 via automated text messaging.

Table 1.

Outcome Measures and Timing of Data Collection

Outcome Measure	Index Child Only	Timing of Data Collection
		Baseline	Weekly for Months 1–72	Month 5	Month 7
Child 1
School absenteeism (primary)		X	X	X	X
COVID-19 preventive behaviors		X		X	X
Stress	X	X		X	X
Sleep disturbance	X	X		X	X
Physical activity	X	X		X	X
Depression and anxiety	X	X		X	X
COVID-19 symptoms			X
COVID-19 exposure			X
COVID-19 testing participation			X
Healthcare utilization for COVID-19 symptoms			X
Parent
Stress		X		X	X
Sleep disturbance		X		X	X
Physical activity		X		X	X
Depression and anxiety		X		X	X
Health literacy		X		X	X
Expectations around COVID-19 testing & vaccines		X		X	X
Self-efficacy		X		X	X
Risk communication & information relevancy		X		X	X

¹Parents will complete outcome assessments of behalf of their child.

²Parents will receive a weekly 5-minute survey via automated text messaging.

Primary Outcome.

The primary outcome evaluated will be the child’s school absenteeism. We will verify self-reported data on absenteeism through school records. The variable for a child’s school absenteeism will have three categories: full, partial, or exempt. A child’s attendance will be categorized as full if they attend the entire school day. A child’s attendance will be categorized as partial if they attend school, but miss 10 minutes or more (e.g., because they arrive late). Finally, a child’s attendance will be categorized as exempt if there are punitive measures in place (e.g., they have been suspended).

Secondary Outcomes.

Secondary outcomes will include self-reported COVID-19 preventive behaviors, including COVID-19 testing at school, vaccine uptake, handwashing, social distancing, and masking. Secondary measures will also include child and parent stress, sleep disturbance, physical activity, and depression and anxiety. We will obtain additional self-reported secondary measures about a child’s COVID-19 symptoms, exposure, testing participation, and healthcare utilization for COVID-19 symptoms. We will collect data on additional secondary measures about a parent’s health literacy; expectations around COVID-19 testing and vaccines; self-efficacy around COVID-19 testing, masking, and discussing COVID-19 with a healthcare provider; and risk communication and information relevancy.

2.5.3. Aim 2 power calculation.

We will enroll 900 elementary school students from 14 schools in the Yakima School District during the 2022–2023 school year. The sample size of 7 schools per study arm and an average of 50 students per school will provide 90% power to detect a difference of at least 4 hours per week (SD=8.0) of in-person school attendance between the intervention and control groups, while assuming intra-cluster correlation (ICC) of 0.05 and type I error rate of 0.05. This sample size will also provide 80% power to detect a difference of 20% or more in COVID-19 vaccination rates between the two study arms, assuming ICC of 0.05 and type I error rate of 0.05.

2.6.4. Aim 2 Analysis plan

The primary analysis will be based on the average number of onsite learning hours per week over the study period for each student. The data will be analyzed using a linear mixed effects model with district and randomization arm as fixed effects, and school and classroom within school as random effects. We will first test for any difference between the randomization arms using α = 0.05 and report the comparisons between arms.

2.7. Aim 3: Process evaluation of COVID-19 risk communication intervention

Purpose.

We will assess implementation outcomes of the COVID-19 risk communication intervention and COVID-19 mitigation strategies with school staff and administrators, parents, and children. The process evaluation will be guided by RE-AIM, which is a widely used framework that explicitly guides research assessment of issues, dimensions, and steps in the design, dissemination, and implementation process of public health interventions. These process evaluations, in conjunction with Aim 2 data, will be used to determine reasons for the effectiveness of the risk communication intervention and the successes with COVID-19 mitigation strategies used by the Yakima School District.

2.7.1. Aim 3 recruitment and data collection

We will use a mixed methods design,²⁵ combining quantitative data collected in Aim 2 with qualitative data collected in Aim 3 during the last two months of the study. Like in Aim 1, semi-structured interviews will be conducted with school staff and administrators and students and focus groups with parents (in both English and Spanish) who participated in the cRCT.

Interviews with school staff and administrators.

Semi-structured interviews will be held with 20 school staff and administrators: superintendent (n=1), principals (n=7), teachers (n=6), and nurses (n=6). Recruitment of school staff and administrators will be conducted using the snowball effect, in which we ask a participant to provide the names and contact information of other school staff and administrators who may be interested in participating in an interview. The semi-structured interview will assess school staff and administrator perspectives, attitudes, and experiences with the Yakima School District’s implementation of the COVID-19 mitigation strategies.

Focus groups with parents.

Four focus groups (2 English, 2 Spanish) will be conducted to examine parents’ (n=40) perceptions of the COVID-19 risk communication intervention and study processes, motivations for participating in the study, and feedback on ways to improve or adapt the risk communication intervention. Parents whose index child was attending a school randomized to the intervention group will be invited to participate in the study. Only parents who complete the baseline survey will be eligible to participate in the focus groups. We will use purposive sampling in order to have representation of parents of students in all grade levels across the seven schools randomized to the intervention.

Interviews with students.

Once parents have agreed to participate in a focus group, we will ask about their interest and permission for their children to participate in a semi-structured interview. We will recruit 20 students. The interviews with students will assess their perceptions and attitudes towards the comic books they received a part of the COVID-19 risk communication intervention.

2.7.2. Aim 3 analysis plan

Qualitative data analysis.

We will use similar qualitative data analysis methods as described in Aim 1 (section 2.5.2) to analyze data collected from semi-structured interviews and focus groups collected in Aim 3.

Data integration.

We will conduct a mixed-methods design with quantitative outcomes data first collected from Aim 2 followed by qualitative data collected from Aim 3. Both quantitative and qualitative data will be analyzed concurrently, but separately. Methodological integration, using a simultaneous bidirectional framework,²⁶ will be used to interpret results that combine quantitative and qualitative data. Results from each approach will be juxtaposed (i.e., physically displayed side-by-side based on outcomes and constructs) to evaluate whether quantitative and qualitative results warrant convergence, expansion, or divergence.

2.8. Compensation to study participants

Aim 1.

School staff and administrators, elementary school students, and parents will be compensated for their time for completing Aim 1 study activities. School staff and administrators who consent and complete a semi-structured interview will receive $30. Parents who consent and attend a focus group will receive $30. Students who consent and complete a semi-structured interview will receive $15.

Aim 2.

Families enrolled in the cRCT will be entered into a drawing to receive vouchers for free pizzas as a thank you for their enrollment. Parents will receive $10 in gift cards on a weekly basis for each child enrolled in the study. Finally, parents will receive a $50 gift card each time they complete an outcome assessment at baseline, month 5, and month 7.

Aim 3.

School staff and administrators, elementary school students, and parents will be compensated for their time for completing Aim 3 study activities. School staff and administrators who consent and complete a semi-structured interview will receive $30. Parents who consent and attend a focus group will receive $20. Students who consent and complete a semi-structured interview will receive $10.

3. DISCUSSION

The ROSSEY study represents an important contribution as one of the first cluster randomized controlled trials to rigorously evaluate a COVID-19 risk communication intervention for elementary school students and families. The project emphasizes health equity by delivering the intervention among some of the most vulnerable populations in Washington state: agricultural communities with a high proportion of Latino residents and migrant workers. Drastic public health measures, along with closures of schools, businesses, public events, and workplaces, slowed the spread of SARS-CoV-2.²⁷ However, the closures these vital outlets for social and economic interactions introduced significant challenges. Closures were particularly hard for communities living in Yakima County who are historically marginalized and disenfranchised. The lack of in-person opportunities for learning widened the achievement gap that existed prior to the pandemic among racial and ethnic minority children who are socioeconomically disadvantaged and those living in resource-limited communities.^28,29

The re-opening of educational settings is critical as schools are safe places that meet many needs for families, especially those families that are under-resourced. For example, schools support the development of a child’s social and emotional skills; provide physical, speech, and mental health therapy; fulfil nutritional needs and facilitate opportunities for physical activity. These basic developmental needs are unmet for families with limited socio-economic resources; challenges with Internet connectivity and equipment; lack of family members who are present at home to assist with virtual learning; and inaccessibility of key services such as school food programs, therapy, and after school programs. In addition, reports of stress and depression have been rising during the COVID-19 pandemic among children, while physical activity has been significantly reduced.³⁰ While reinstituting onsite learning in schools is a priority, school administrators have noted concerns to return to in-person instruction due to the health risks associated with COVID-19.³¹

SARS-CoV-2 testing and vaccination are practical strategies for instilling confidence in the safe return to school for students, families, and staff.^32,33 In addition, implementation of accurate, science-based risk communication can help educate staff, students, and parents on the benefits and safety of testing and vaccination, address the information gap, and quelch false information. With the growing prevalence of vaccine hesitancy, risk communication may serve an essential function to inform families about the role of testing and vaccines as part of mitigation strategies to allow for safe in-person instruction. The study findings have potential for translational impact into policy and practice. Schools have been identified as settings with extraordinary influence to promote children’s health through policy and practice change. The findings of this study will provide the evidence that can facilitate policy decisions and best practices at schools by identifying effective school-level intervention activities and processes that can facilitate adoption of the intervention.

3.1. Strengths and limitations

The ROSSEY study represents over 20 years of collaborative work between community and academic research partners in a rural region of Washington state. CBPR enabled ongoing incorporation of community perspectives throughout the intervention design, implementation, and evaluation.¹⁶ Our CBPR approach is responsive to calls for cultural humility when developing community-based interventions, shortens the timeline from research to practice, and increases potential for integration and sustainability locally.³⁴ An additional strength includes the focus on schools and integration of research activities into existing curricula. School-based interventions allow efficient delivery to many students and families.

Our study protocol does, however, have some limitations worth noting. While the risk communication intervention will be important to educate students and their families about COVID-19 and ways to mitigate infections and disease, improving and sustaining COVID-19 prevention behaviors will require adequate resources and support from the school district, local health departments, and other important community-based and health organizations. With how quickly policies and procedures governing schools and local communities can change, trends in COVID-19 infection, and timely implementation of risk communication may also present a challenge that could limit the reach of this study. Our study also relies on self-reports, which may inaccurately reflect study participants’ true COVID-19 prevention behaviors. For self-reported data on COVID-19 testing, however, we will be verifying through school records to mitigate this limitation.

3.2. Dissemination of findings

We will disseminate ROSSEY study findings using an established framework to enhance the value and usefulness of research deliverables.³⁵ We will first establish a dissemination subcommittee among our research team to oversee the process. With committee guidance, we will identify standardized information that will be included in reports throughout the different phases of the project to ensure transparency to community members and funders. We will report study findings on the overall impact of the intervention on the outcomes of interest, identify contextual factors that impact the intervention and COVID-19 mitigation strategies implemented at schools, and include perspectives from multiple stakeholders in our reports. We will share our findings through community briefs; scientific publications; and presentations with school stakeholders, community members, researchers, practitioners, and policymakers. We will also make use of social media platforms (e.g., Facebook, Twitter, Instagram) to share our findings with the broader Hispanic/Latino communities. We will collaborate with our CAB members and language experts to ensure that communication materials for the community are accessible in Spanish and English and are culturally appropriate.

We will also evaluate our dissemination plan using the Prevention Science Impact Framework developed by the Centers for Disease Control and Prevention. Our study used this framework for a previous study.³⁶ The framework includes measures for: disseminating science (e.g., peer-reviewed publications, conference presentations, white papers); creating awareness (e.g., number of people reached through virtual events); catalyzing action (e.g., new partnerships/collaborations, creation of advocacy groups); effecting change (e.g., community/clinic/health system practice change); and shaping the future (e.g., reducing mortality and morbidity). Our research dissemination process aims to share relevant, meaningful findings with diverse audiences in order to catalyze action and shape the future through evidence-based changes in schools, communities, research, policy, and public health practice.