Engaging Primary Care Clinic Personnel in the Implementation of a Family-Based Intervention

Abstract

As the prevention field moves towards integrated care models that facilitate accessibility of evidence-based interventions, there is a need to capitalize on innovative settings and strategies to effectively implement such programs. This manuscript describes lessons learned in the implementation of eHealth Familias Unidas–a family-based program for Hispanic parents and adolescents for the prevention of substance use, sexual risk behaviors, and sexually transmitted infections–in pediatric primary care settings as well as the process of engaging clinic personnel in the implementation process. (Am J Public Health. 2026;116(S1):S22–S27. https://doi.org/10.2105/AJPH.2025.308340)

Substance use, sexual risk behaviors (e.g., condomless sex), and sexually transmitted infections (e.g., HIV) constitute significant public health concerns for Hispanic youths.^1–3 Our team developed and tested an online, family-centered prevention intervention, eHealth Familias Unidas Primary Care (eHealth FUPC), for the prevention of these outcomes among Hispanic adolescents.⁴ Given the fragmented delivery of behavioral health services, integrating interventions such as eHealth FUPC into primary care is increasingly supported to improve access for Hispanic families.^5,6 Thus, we implemented the eHealth FUPC intervention in primary care clinics across South Florida.⁴

INTERVENTION AND IMPLEMENTATION

The reach, efficacy, adoption, implementation, and maintenance framework guided implementation to determine overall public health impact.⁷ Specifically, we sought to evaluate the percentage and characteristics of participants engaged (reach), efficacy of eHealth FUPC on health outcomes (efficacy), proportion and types of clinics adopting the intervention and their characteristics (adoption), and fidelity to the intervention protocol (implementation).

Implementing innovative programs in pediatric primary care settings often faces systemic barriers, limited organizational support, and sustainability issues.⁸ In previous work implementing Familias Unidas in schools,⁹ gaining buy-in from school administrators was a major hurdle. To ensure successful implementation of eHealth FUPC in South Florida primary care clinics, we engaged both clinic administrators and clinic personnel early in the decision-making process. Before receiving funding, our bilingual Hispanic team focused on engaging and building relationships with clinic administrators, using bilingual materials to foster support. We began by meeting with chief executive officers and medical directors to present eHealth FUPC, its evidence base, and potential benefits for clinic patients, emphasizing the role of frontline clinic personnel (e.g., nurses, clerical personnel) in promoting and potentially delivering the program. Administrators were concerned about staff burden, so we clarified that their role was limited to sharing flyers during work hours, and if they chose to deliver the intervention, it would take place outside work hours, for example. We addressed any remaining questions and formally requested letters of support to include in our proposal to underscore the administrators’ commitment and endorsement.

After securing funding, we used our existing relationships with clinic administrators to build relationships and engage with clinic personnel. Administrator support facilitated subsequent meetings and presentations with clinic personnel to explain the study and their role. We joined with clinic staff—nurses, physicians, and medical assistants—by building rapport, engaging at the right moments, emphasizing the value of their roles in serving Hispanic families, and highlighting the program’s benefits. This was key to gaining buy-in from those promoting and delivering eHealth FUPC. Administrators and personnel supported the program’s goals and agreed that evidence-based programs and culturally appropriate programs for Hispanic families are scarce and needed.

Despite the overwhelming support for eHealth FUPC, clinic administrators and personnel identified organizational barriers to implementation and shared ideas to solve problems and generate solutions. For example, workflow disruption was a common concern.¹⁰ To minimize this, we limited clinic visits to one team member at a time and arrived early to avoid delays. Another concern was the amount of time that it would take to promote and explain the program to families. To help, we created a mock “prescription” (Figure 1) that described the program and could be easily handed to eligible families. This tool reduced the burden on the physician and functioned as a powerful endorsement, using the credibility they hold with Hispanic families.

FIGURE 1—

Sample “Prescription”: eHealth Familias Unidas Primary Care, South Florida, 2017–2022

Throughout the study, we kept clinics updated on recruitment progress with frequent contact via in-person visits and emails. We reminded administrators and personnel to share referrals and report any issues. To show appreciation, we occasionally brought coffee, donuts, and pastelitos (Cuban pastries), which helped personnel feel valued. We also invited clinic personnel to coauthor study articles. Successful implementation requires time, flexibility, and strong collaboration to meet clinic needs and address challenges. In less inherently trusted settings, building relational trust through early stakeholder engagement and demonstrating the intervention’s value is key to success.

PLACE, TIME, AND PERSONS

Recruitment, intervention delivery, and follow-up assessments occurred from 2017 through 2022.⁴ We recruited Hispanic parent–adolescent dyads across 15 pediatric primary care clinics in South Florida. Adolescents were aged 12 to 16 years and had a mean age of 13.9 years (SD = 1.37); girls made up 52.9% of the sample. The majority of adolescents (55.5%) were US born. Before beginning the assessment survey for the study, parents and adolescents were assured that their responses would not be shared with anyone (including the adolescent’s responses with the parent and the parent’s responses with the adolescent). To further increase the validity of adolescents’ responses, parents and adolescents completed study surveys separately so that adolescents could be confident that their parents would not see their responses.

PURPOSE

eHealth FUPC is designed to prevent substance use and risky sexual behaviors among Hispanic youths. This 12-week online family intervention includes parent group videos focused on effective parent–adolescent communication, parental monitoring of youths’ activities, and parental investment in positive outcomes for youths. Families also engage in four online family sessions in which parents, with facilitator guidance, apply skills from the video sessions and interactive exercises. These sessions involve practicing effective communication on culturally relevant topics, such as parenting in two cultures and how differences in the way parents and youths acculturate can affect family dynamics. Furthermore, the role of family, a very strong cultural value in Hispanic culture, is at the forefront of the intervention and is used as a framework through which adolescents’ outcomes are targeted. As many of the clinic administrators and personnel were also Hispanic, they were familiar with and understood the cultural factors that informed the intervention.

Clinic staff responsible for intervention delivery received 24 hours of training from the eHealth FUPC clinical supervisor. Training included review of the intervention manual, didactic presentations, videotape reviews, and role-playing. To ensure implementation quality, 25% of intervention sessions were independently rated to assess adherence to the intervention manual and support facilitator supervision.

EVALUATION AND ADVERSE EFFECTS

Because the study evaluating eHealth Familias Unidas in primary care settings is still ongoing, we briefly describe previously published findings from the evaluation of eHealth Familias Unidas in school settings.¹¹ We evaluated the intervention in a randomized controlled trial with 231 parent–adolescent dyads (eHealth FUPC: n = 113; prevention as usual: n = 117), who we followed for 12 months postintervention delivery at three assessment time points (details regarding recruitment and analysis can be found in Estrada et al.¹¹). Results, shown in Table 1, indicate that eHealth Familias Unidas, compared with prevention as usual, reduced past 90 days’ drug use trajectories.¹¹ When evaluating the specific categories of drug use, we found significant differences in the trajectories for past 90 days’ use of marijuana, inhalants, prescription drugs, and cigarettes.¹¹ There were no intervention effects for sexual risk behaviors (e.g., condom use). It is possible that the lack of effects for sexual risk behaviors are related to a small sample of youths who engaged in sexual behaviors across the study period.

TABLE 1—

Baseline Comparisons by Condition on Outcomes: eHealth Familias Unidas, South Florida, 2014–2016

Outcomea	eHealth Familias Unidas, Mean ±SD	Prevention as Usual, Mean ±SD	ba (95% CI)
Drug use			−1.16 (−1.33, −1.00)
Marijuana	1.01 ±8.52	0.20 ±1.27	−0.52 (−0.90, −0.15)
Inhalants	0.85 ±8.51	0.07 ±0.83	−1.19 (−1.64, −0.75)
Cocaine	0.82 ±8.50	0.07 ±0.83	−0.11 (−0.59, 0.37)
Other drugs	0.82 ±8.50	0.00 ±0.00	0.06 (−1.76, 0.40)
Prescription drug use	0.04 ±0.31	0.86 ±9.23	−1.34 (−2.33, −0.35)
Cigarette use	0.53 ±4.80	0.87 ±9.23	−1.05 (−1.72, −0.39)
Alcohol use	0.25 ±1.46	1.02 ±9.24	0.02 (−0.25, 0.28)
Condomless sex	0.11 ±0.62	0.08 ±0.55	0.02 (−0.31, 0.35)

Note. CI = confidence interval.

^a The estimated unstandardized coefficients are drawn from Estrada et al.¹¹

There are no known adverse effects related to this study.

SUSTAINABILITY

Given the efficacy of eHealth FUPC, it is desirable for the program to continue being offered in primary care settings. We evaluated the effectiveness of eHealth FUPC in a separate randomized controlled trial across 15 diverse primary care clinics (i.e., federally qualified health care centers, private clinics, community clinics, academic health clinics, and hospital clinics) that were in urban settings and served populations that were 50% Hispanic (Y Estrada, A Lozano, B Graefe et al., unpublished).⁴ Building on these findings, a subsequent hybrid type 1 trial is now assessing the intervention’s effectiveness, implementation, and sustainment.¹² Notably, many clinics from the initial trial opted into the ongoing study, reflecting continued interest and commitment. A key component of this rollout is the sustainment period, during which research staff disengage from recruitment, allowing evaluation of postsupport outcomes and long-term intervention maintenance.¹²

Collecting implementation outcomes in the trial discussed here helped us identify barriers, facilitators, and predictors of sustainability. Preliminary findings suggest that clinic personnel’s perception of their organization’s implementation climate influences attitudes toward evidence-based practices.¹³ Positive personnel attitudes, along with observed patient benefits, may encourage continued program delivery. For example, preimplementation planning can include assessing a clinic’s implementation climate and using this information to codevelop a tailored blueprint, ideally with clinic personnel, thereby promoting buy-in, implementation, and sustainability. Furthermore, because the US Preventive Services Task Force deems programs such as eHealth FUPC beneficial, it may become eligible for reimbursement without copay, supporting long-term sustainability in primary care.⁵

PUBLIC HEALTH SIGNIFICANCE

The eHealth FUPC intervention addresses a critical gap in evidence-based prevention in primary care. By embedding a culturally tailored, family-based program in a trusted health care setting, this study has the potential to revolutionize how prevention is delivered—equitably reaching Hispanic youths and significantly reducing disparities in substance use, risky sexual behaviors, and sexually transmitted infections. By addressing health outcomes through culturally grounded, family-based strategies, this intervention aligns with the Prevent pillar of the Ending the HIV Epidemic in the US initiative¹⁴ and advances prevention efforts among Hispanic adolescents, who are disproportionately affected by HIV.