Adapting an evidence-based positive youth development intervention to prevent sexual and teen dating violence

Adapting evidence-based interventions (EBIs) guided by implementation science frameworks is a promising way to bridge the gap between research and practice and advance effective sexual violence prevention in schools.

Abstract

Adapting evidence-based interventions (EBIs) guided by implementation science frameworks is a promising way to accelerate the translation of effective violence prevention in schools. School-based interventions offer an opportunity to reduce the risk of multiple forms of violence, including sexual violence (SV) and teen dating violence (TDV). EBIs in schools reach large populations of adolescents, including those underserved in other settings. Although specific SV/TDV prevention programs exist, evaluations indicate limited effectiveness over time. We adapted systematically the Youth Empowerment Solutions (YES) violence-prevention EBI using key adaptation steps described in implementation science frameworks to expand the scope of YES to integrate an SV/TDV focus and meet the needs of local youth. In the formative project year, the team adapted YES to integrate SV/TDV content informed by key steps outlined in frameworks including ADAPT-ITT, research-tested intervention programs, and map of the adaptation process. These steps include: (a) assess school and student needs, (b) identify, select an EBI, (c) consult with experts with knowledge in the new topic area (SV/TDV), (d) collaborate with community partners and stakeholders, (e) identify areas for adaptation while maintaining fidelity to core elements, (f) train staff, (g) pilot test adapted materials, (h) implement, and (i) evaluate. We developed the YES for Healthy Relationships (YES-HR), a school-based prevention program that retained core elements of YES, including content related to mastery, adult resources, leadership skills, and community engagement, while integrating SV/TDV-specific content (e.g., consent). Implementation science adaptation frameworks are useful in guiding the systematic adaptation of existing EBIs to meet the needs of youth.

Implications.

Practice: Adapting evidence-based interventions (EBIs) guided by implementation science frameworks can help meet the needs of populations and accelerate the application of research findings into practice.

Policy: Policymakers who want to address urgent public health issues efficiently and effectively can support adapting existing EBIs versus developing new interventions.

Research: Future research can investigate the effectiveness of systematically adapting EBIs to address new, emerging health issues with common risk factors.

BACKGROUND

We have an urgent need to facilitate the integration of effective teen dating violence (TDV) and sexual violence (SV) prevention interventions in community settings. TDV and SV are serious public health issues with significant short- and long-term consequences, including mental health problems, sexual risk behaviors, substance use disorders, and heightened risk of future violence [1,2]. Although specific SV and TDV prevention programs exist, evaluations indicate that many of these programs have limited effectiveness over time [3]. Yet, developing new interventions de novo is time and resource intensive [4]. One way to accelerate the advancement of effective interventions to reduce TDV and SV is to build on other evidence-based violence-prevention approaches.

Most researchers developing and implementing violence-prevention programs have compartmentalized interventions by narrowing their scope to specific address outcomes (e.g., TDV and SV) [5]. Notable interconnections, however, exist across forms of violence (e.g., SV, peer-to-peer aggression) and this is a central tenet of recent initiatives to identify cross-cutting approaches to prevention; that is, effective approaches may have broad applications for prevention across forms of violence [6]. In addition, most youth who experience violence experience multiple forms that share many risk and protective factors [7,8]. Prevention programs may have greater benefits and be more efficient by focusing on core elements that address shared risk and protective factors across different forms of violence. Interventions that build youths’ skills and confidence, for example, may help them think critically, develop connections with the community, and create positive community change and are likely to have benefits that extend across different forms of violence [8,9]. Consequently, building on the well-developed body of intervention research that addresses peer-to-peer interpersonal violence prevention and positive youth development is a promising approach to effectively reducing risk of TDV and SV.

Adaptation frameworks from implementation science are useful in guiding the systematic adaptation of evidence-based youth violence interventions to address TDV and SV. Adaptation, from the perspective of dissemination and implementation (D&I) research refers to the degree to which an evidence-based intervention (EBI) is modified to improve the fit with local conditions and needs [10]. Most empirically studied adaptations focus on modifying EBIs to improve the fit between the intervention, the context, and the population served; this has been accomplished primarily through considering race, ethnicity, service setting, location, and organizational characteristics [11]. These types of adaptations focus on enhancing fit without eroding fidelity of key intervention components (e.g., fidelity-consistent adaptations) [12]. Yet, researchers acknowledge that the systematic study of adaptation is still evolving [11]. We have a critical need to advance translation of effective interventions in order to address urgent and emerging health issues, including violence among youth; D&I adaptation frameworks can accelerate this process through supporting fidelity-consistent adaptations for violence-prevention EBIs to address these issues and optimize the intervention based on the needs of a specific population and setting [11]. Few, however, have applied D&I frameworks to systematically adapt an intervention to expand its focus in order to address emerging but related health issues and population needs.

Adaptation frameworks can aid in expanding intervention scope to better fit population needs, such as modifying an evidence-based peer-to-peer violence intervention to address sexual and relationship violence prevention. This expanded scope in D&I adaptation research is congruent with efforts to integrate prevention approaches across forms of violence and capitalize on advancements in effective approaches to violence prevention. Building on existing evidence-based interventions may be an efficient and effective way to reduce TDV and SV and address common risk and protective factors.

Our objective was to adapt systematically the Youth Empowerment Solutions (YES) violence-prevention EBI to create YES for Healthy Relationships (YES-HR) using key adaptation steps described in implementation science adaptation frameworks. Guided by these frameworks, we expand the scope of YES to integrate a focus on sexual and relationship aggression while retaining core elements of positive youth development and empowerment that address common risk and protective factors for violent behavior more generally. The original YES for Peaceful Communities program was guided by empowerment and ecological theories within a positive youth development context [13]. The program was designed to enhance the capacity of adolescents and adults to work together to plan and implement community change projects. The curriculum includes six units: (a) Youth as Leaders, (b) Learning about Our Community, (c) Improving Our Community, (d) Building Intergenerational Partnerships, (e) Planning for Change, and (f) Action and Reflection. The curriculum was developed through an iterative process that started with program staff documenting their activities with youth. These outlines were formalized as curriculum sessions. Each session was reviewed by the program and research staff and revised based on the underlying theory and practical application. This theoretically based, field-tested curriculum was designed to be easily adapted and implemented in a diverse range of communities. YES was developed using a community-engaged approach with partners in Flint, MI [14]. The curriculum provides structured lesson plans and is responsive to local culture, creates opportunities for intergenerational collaboration, and prepares youth to plan and implement community change. YES incorporates empowerment theory and principles of positive youth development through content focused on confidence and skill building (intrapersonal component), activities to help youth think critically and develop positive community connections (interpersonal component), and designing and implementing a community change project (interactional component; see Fig. 1) [9]. These components of empowerment are considered core elements of the intervention contributing to its effectiveness and, thus, were consistent between YES and YES-HR. The intervention applies an active learning approach organized around the six units to integrate and reinforce empowerment theory and positive youth development [13]. Table 1 provides a brief summary of each unit. Key findings from a recent study of YES in Flint and surrounding Genesee County, MI, support the intervention’s effectiveness; results indicated that YES is effective in enhancing psychological empowerment which, in turn, reduced risk of delinquency and increased the likelihood of positive outcomes, such as prosocial behaviors [9]. In addition, YES is well suited for adaptation to address SV and TDV as it was originally developed for youth in early adolescence [9,15], has been adapted for different cultural contexts and populations, and includes an adaptation guide that identifies core nonadaptable elements and adaptable elements of the program (www.yes.sph.umich.edu).

Fig 1.

| Conceptual model of empowerment theory underlying the Youth Empowerment Solutions (YES) and YES for Healthy Relationships (YES-HR) interventions. This conceptual model helped guide the adaptation of YES to YES-HR by identifying those core elements of the intervention relating to empowered processes critical to intervention effectiveness.

Table 1.

| Curriculum description for Youth Empowerment Solutions (YES) and YES for Healthy Relationships (YES-HR) by unit

Original YES intervention		YES-HR intervention
Unit	Unit description	Unit	Unit description
Youth as Leaders	• Builds group norms and team identification	Building Healthy Relationships	• Explore personal values
	• Helps build leadership efficacy		• Identify personal boundaries
	• Opportunities to complete small projects and engage early in program		• Explore and define the meaning of consent in relationships
			• Critically examine gender stereotypes and their portrayal in media
			• Learn about power differentials
Learning About Our Community	• Build skills to identify and assess community conditions influencing healthy development	Learning About Our School Community	• Build leadership efficacy and leadership skills
	• Community windshield tour and photovoice methods		• Identify adult partners
			• Learn about being an effective bystander
			• Build skills to assess positive and negative community conditions
			• Photovoice introduction
Improving Our Community	• Learn to make a difference through community development	Improving Our School Community	• Learn to make a difference through community development
	• Practice thinking critically about how actions can strengthen communities		• Learn to think critically about how actions can help strengthen schools
Building Intergenerational Partnerships	• Work in equal partnership with adults	Planning for Change	• Develop concrete proposals that include project description, goals, budget, and timeline
	• Learn about power differentials		• Build support for project with school and greater community
	• Apply decision-making power
	• Interview adult volunteers
Planning for Change	• Develop concrete proposals that include project description, goals, budget, and timeline	Action and Celebration	• Project implementation
	• Build support for project among community		• Reflect on project and process
			• Community celebration
Action and Reflection	• Project implementation
	• Reflect on project and process
	• Community celebration

Multiple D&I frameworks exist to guide adaptation of EBIs, including ADAPT-ITT [16], map of the adaptation process (MAP) [17], and research-tested intervention programs (RTIPs) [18], among others. These adaptation frameworks share key steps as described by Escoffery et al. [19]. The key steps include the following: (a) assess community needs, (b) identify and review the intervention, (c) consult with experts and stakeholders, (d) consult with stakeholders, (e) decide what needs adaptation, (f) adapt the original program, (g) test the adapted materials, (h) train staff, (i) implement, and (j) evaluate (Table 2). We revised the key steps to consolidate integrated activities (e.g., identify and review the intervention) and practical considerations (e.g., testing adapted materials and revising curriculum activities based on feedback prior to training staff). We focus on adapting a school-based intervention as EBIs in schools offer a unique opportunity to reduce the risk of multiple forms of violence among youth, including SV and TDV.

Table 2.

| Key adaptation steps and descriptions (adapted from Escoffery et al., 2018)

Steps	Step description
1. Assess local needs and capacity	• Meetings with school partners regarding student needs
	• Identify teen dating violence (TDV) and sexual violence (SV) as a prominent issue among youth in collaboration with school partners
2. Identify and review the intervention	• Identify an evidence-based intervention (EBI) focused on empowerment, violence prevention
3. Consult with TDV and SV experts	• Input from research team members with expertise in TDV and SV following original program review
	• Identify TDV and SV issues to address in new curriculum
4. Consult with stakeholders	• Seek input from teachers and administrators
	• Identify partners who can aid in championing the program
5. Decide what needs adaptation	• Evaluate how new population needs differ from those for the original program
	• Identify areas where EBI needs to be adapted and possible changes to content, structure and delivery methods
	• Retain core EBI elements
6. Make needed adaptations	• Develop adaptation plan
	• Collaboratively adapt original program
	• Maintain effective core program elements
	• Develop updated training program for Youth Empowerment Solutions for Healthy Relationships
7. Train staff	• Select and train participating teachers
8. Pilot test the adapted intervention	• Pretest adapted materials with appropriate population
	• Modify EBI further based on pretest
9. Implement	• Develop implementation plan
	• Conduct initial delivery of program to intended population
	• Provide technical assistance during program delivery
	• Train study staff in evaluation, including observations
10. Evaluate	• Collect implementation data in multiple formats
	◦ Observations using established rubric
	◦ Teacher activity logs, open-ended feedback
	• Collect behavioral outcome data
	• Evaluate data to inform additional adaptations for fit, fidelity

The purpose of this paper is to (a) describe key steps in the systematic adaptation of YES to YES-HR to prevent SV and TDV among youth, (b) present the initial implementation evaluation results for YES-HR in its first year of delivery (i.e., with Cohort 1), and (c) discuss how the initial implementation evaluation was used to inform further refinement of YES-HR to improve its implementability in community schools and, consequently, the effectiveness of the intervention in reducing TDV and SV among youth.

METHOD

The adaptation of YES-HR was the first step in a group-randomized trial (GRT) [20] conducted with middle schools. During initial recruitment, six participating schools, from five school districts, were randomly selected to receive either the YES-HR intervention or serve as a matched comparison group. We focus this paper on the schools receiving YES-HR. The intervention was implemented in 20 classrooms by five teachers. It is a universal prevention strategy, received by all eighth grade students in mainstream (not special education) classrooms in the schools. Schools included in the study are from Wayne County, in southeast Michigan, and are moderate-high risk of violence based on community risk factors; this risk assessment was developed from a composite rating of publicly available community data, including poverty rate, household income, minority composition, high school graduation rates, and proficiency on the Michigan Merit Exam (see Table 3).

Table 3.

| Community demographics

	District 1	District 2	District 3	District 4	District 5
Percent below poverty	14.7%	7.8%	19.7%	11%	20.7%
Median household income	$55 308	$62 591	$44 525	$48 924	$41 724
Percent nonwhite	8.9%	4.3%	49.5%	11.3%	22%
High school graduation	89%	90%	86%	86%	80%
Proficiency on Michigan Merit Exam (math)	24%	25%	11%	13%	10%
Proficiency on Michigan Merit Exam (reading)	57%	66%	38%	64%	47%

Adaptation of the YES-HR program

A summary of the adaptation steps is provided in Table 1. The YES-HR adaptation was completed by an interdisciplinary team of behavioral scientists, community psychologists, implementation scientists, social workers, school and community outreach specialists, and methodologists at two research universities. The researchers have expertise in community-based intervention development and evaluation, health disparities research, youth violence, TDV and SV, and youth development from disciplines including public health, social work, and psychology. The YES-HR adaptation and implementation were completed in close collaboration with administration and staff in our partner schools. Administrative support was key from the level of the superintendent and school board to the principals and multiple staff—including guidance counselors, special education teachers, and behavioral support specialists.

Step 1: assess local needs and capacity

The Strengthening Supports for Healthy Adolescent Relationships and Environments (SHARE) study is a longitudinal study addressing modifiable risk and protective factors for perpetration of sexual and intimate partner violence among youth in Wayne County, MI, conducted by the study team members to assess local health needs and emerging issues. The study focused on Wayne County because children and youth experience notable risk factors for TDV, SV, and other poor health outcomes. A notable proportion of children and youth in Wayne County, for example, live below the poverty level (35.5%), higher than the state average (21.7%) [21], and 59.4% of Wayne County’s students are eligible to receive free or reduced-price lunches compared to 46.1% of Michigan students [22]. Youth in Wayne County also experience concerning rates of crime and violence, with over 3,000 juvenile arrests in 2013, nearly twice as many as any other county in Michigan [23]. Results of the SHARE study indicated that SV and TDV are significant issues among local high school- and middle school-aged youth [24]. Administration in our partner schools and members of the research team felt there was a critical need to effectively address SV and TDV before first offense or victimization. As a result, prevention efforts for the intervention focused on early adolescence (i.e., middle school-aged youth). Partner schools enthusiastically collaborated in the project as it provided an opportunity to modify environments and build protective factors identified in the SHARE research in order to reduce SV and TDV perpetration.

Step 2: identify and review interventions

Several school-based programs for SV and TDV prevention have been evaluated with mixed results [25–27]. DeGue et al. [28] identified a need to expand strategies to focus on ecological factors beyond the individual. Programs that address primarily individual-level characteristics may have only limited effectiveness in that they do not provide youth with opportunities to become engaged in developing solutions that address issues associated with SV and TDV. We (the study team) reviewed existing interventions [26,29–31] but felt that the important component that was missing in most of the other programs was a more hands-on, empowerment-based approach to preventing TDV/SV. We did not want a program that adopted a largely didactic approach; we reviewed the most commonly implemented programs and did not feel that any provided the opportunity to assess their environment and proactively make changes they felt would be meaningful. Consequently, with school district collaborators, we investigated other possible violence-prevention interventions that addressed these issues as central aspects of the program and selected the YES intervention. Although YES had not been specifically designed or evaluated for outcomes related to perpetration of SV and TDV, the research team recognized that the intervention addressed many of the important protective factors identified in the SHARE study, such as school connectedness, hopefulness, and community engagement. Given the evidence of effectiveness with other youth violence outcomes, YES was selected for adaptation.

Step 3: consult with TDV and SV experts

Research team members with expertise in TDV and SV prevention identified specific topical areas to integrate into the YES-HR intervention. These included personal values and boundaries, defining healthy relationships, power and power imbalance, consent, and the role of bystanders. New activities focused on TDV/SV were informed by existing TDV/SV interventions, including Safe Dates [32] and Shifting Boundaries [27] and developed by the research team members with expertise in this area; results from the SHARE study informed the way the team developed and integrated YES-HR activities. Activities were either adapted from existing activities in the YES curriculum or added based on previous research, expertise, and experience of the team members or in consultation with state and local violence-prevention programs. In addition, new activities were reviewed by an SV/TDV expert outside the core research team to support content validity. The full research team met to discuss these new areas and options for program activities to address them.

Step 4: consult with stakeholders

Stakeholders included school staff and administrators, parents, and students. In each implementation school, four focus groups were held, including one with school staff, one with parents, and two with students, in gender-segregated groups. Study team members conducted interviews with school administrators, including superintendents, principals, and vice-principals. The goal of the interviews was to assess the perceived needs and assets of the school and community related to healthy relationship behavior and violence prevention and to identify priorities. Students and parents reported that school was an important setting for prevention and education programs, with significant gaps in existing programs identified. The teachers, administration, and other school staff felt that adapting the YES program to create YES-HR would be well suited to meet the needs of the youth they serve. We planned to integrate the program into the social studies curriculum based on key stakeholder input. Throughout the adaptation process, community stakeholders, including youth serving, and victim services organizations were consulted. We selected social studies as the curricular area for YES-HR as the learning goals of social studies in the eighth-grade core curriculum aligned most closely with the content and activities of YES-HR. All decisions, including the length and timing of the program, were made in consultation with school administrators.

Step 5: decide what needs adaptation

We (the research team) met and collectively discussed how to integrate these new topical areas into the YES curriculum, including timing and order, and specific activities related to the revised lessons. The original YES curriculum includes an adaptation guide, focused primarily on cultural adaptation, and we used this guide to identify and retain core elements of the program while making topical adaptations. The YES Adaptation Guide outlines core curriculum components (http://yes.sph.umich.edu/curriculum/adaptation-guide/). Core content components include sessions that are focused on the three main components of empowerment theory: (a) intrapersonal (attitudes and beliefs regarding confidence and control); (b) interactional (critical thinking skills, awareness of causal connections, and resource mobilization); and (c) behavioral (strategies and action to practice beliefs and skills to influence community in positive ways). The YES curriculum Adaptation Guide provides information that links specific curricular sessions to each of these core components. We reviewed how the YES-HR target population and setting would differ from the original YES and what logistical, structural, and activity changes were needed to accommodate the new setting and focus, informed by the adaptation guide. We also discussed which nonessential elements of YES could be eliminated or modified to integrate the SV/TDV-specific content.

Step 6: adapt the original program

We developed an adaptation plan to create the YES-HR intervention. After deciding what needed adaptation, the team developed a strategy to make the proposed changes. This included reviewing evidence-based approaches to address new topic areas (e.g., consent, see [27,32]), developing new content and related activities informed by the SHARE study, revising specific lessons to integrate the new activities, adjusting lesson length, and restructuring the curriculum as needed to enhance flow with existing and new activities. Specifically, new content was added that focused on relationship skills, such as communication and consent, as well as school-level change around social norms and bystander intervention. New activities included ball toss, lightning rounds, cross the line, and jeopardy. We also updated the focus of role-plays, small and large group discussions, and videos to address the new content areas and revise existing content to more directly address relationship norms and behaviors. Our team met regularly to discuss the proposed changes and come to a consensus before changes were applied. We also adapted the implementation evaluation materials, including the lesson activity logs and the intervention training for staff, based on the new, adapted intervention.

Step 7: train staff

All intervention staff, interns, and teachers received YES-HR training from the study team. Training counted as part of teachers’ annual professional development hours. Training consisted of two half-day workshops, similar to the original YES training. The goal of the workshops was to familiarize staff with curriculum goals, flow, and content and to practice delivering modules. The first workshop focused on the philosophy of youth empowerment, a readthrough of the curriculum, discussion of our past experience implementing YES, and questions and answers. The second workshop focused on the first three modules and program-planning modules with a discussion of the community projects.

Step 8: pilot test the adapted intervention components

We pilot tested selected adapted materials with our population of interest (i.e., middle school-aged youth at high risk of violence in low-resource communities) in a nonstudy community. We focused on activities that underwent notable changes and or needed additional testing given logistical issues of delivery during the school day. The testing included lesson facilitation, followed by participant evaluation and suggestions for improvement. Several study team members were present during the pilot testing to observe lesson delivery and make additional suggestions for improvement. The youth provided specific feedback on the activities, including what needed to be changed to better engage students. Following the pilot testing, the team reviewed the feedback and made additional adaptations to the intervention.

Step 9: implement

We developed an implementation plan designed to meet the needs of our key stakeholders and the educational setting. This included providing all adapted program packaging and materials to the teachers, including the curriculum manual, handouts, video and audio resources, and activity supplies. The program was to be delivered once weekly over the course of the academic year as part of this curriculum. We identified teachers as the primary implementers of YES-HR; social work interns assisted with program delivery to support initial intervention integration into the school day, classroom management, and logistics and implementation data collection. Research team members also made provisions for as-needed technical assistance to aid in ameliorating barriers to program delivery.

Step 10: evaluation

We developed a comprehensive plan to evaluate the implementation and effectiveness of the adapted intervention. This included choosing measures to assess behavioral and implementation outcomes and developing a data collection strategy and an approach to conduct a process evaluation to inform and improve program implementation. We address specifically the implementation process evaluation and outcomes in the current manuscript and how these informed the second year of program implementation. The implementation evaluation included observations of classroom sessions with ratings of program elements and detailed field notes for fidelity.

Measures

We measured multiple dimensions of fidelity as described by Proctor et al. [33], including adherence and quality delivery, using guided classroom observation. Research team members participating in the observations received training addressing observation protocol and forms and the rubric to guide observation scoring. Two team members sat in the back of the room during selected key classroom sessions and completed the scoring based on the provided rubric. Team members also observed several classroom sessions for a single teacher on a given day. The quality delivery included four program elements rated on the observation form: effective communication, student engagement, shared control, and respectful interactions. The adherence rating was evaluated using a single item asking to what extent the lesson activities were completed as written. The ratings for each element ranged from 1 (low) to 7 (high). We created an average between raters for each session observed. We assessed interrater reliability by calculating percent agreement between the two raters on a subset of observations. Raters observed classrooms once a month, approximately, rating every fourth classroom session. Interrater reliability was calculated for each of these observations. Our interrater reliability was 0.74–0.99. For quality delivery, we created a mean across the four program elements to develop a score per session. To account for possible fluctuations in fidelity across sessions in the curriculum, we created a mean score for each fidelity dimension (adherence and quality delivery) within each classroom to evaluate overall fidelity. The form structure and rating was modeled after the Evidence-Based Prevention and Intervention Support Center’s (EPIS) project observation form [34]. During initial observation sessions, project team members reviewed and discussed ratings to refine the form as needed and support interrater reliability. The observation forms also included detailed field notes by the observers.

We also trained observers to take detailed field notes during observation sessions. These field notes, as well as informal feedback from teachers and students during the first year of program delivery, are included in our analyses.

RESULTS

Table 1 provides a summary of adaptations made to the original program for YES-HR following the formative year of the project and its first implementation. Documentation of adaptations is guided by Stirman et al.’s classification system [35].

Adaptations made to YES for YES-HR

Context: setting and personnel

Setting

The program was adapted to be integrated in to the school curriculum in order to support the universal implementation of the prevention program. Changing the curriculum from an after-school program to one integrated into the school curriculum required contextual modifications. First, we had to change the lesson length given that the periods during the school day were shorter than the allotted after-school time in the original program. We also needed to align the lessons with State educational standards in the social studies curriculum.

The original YES focuses on students affecting change in the neighborhoods in which they lived. As the program was integrated as part of the school day, we adjusted to focus on the school as the community environment. We modified activities, such as Photovoice, an exercise in critically evaluating assets and liabilities in neighborhoods, to focus was on the school community.

Personnel

The YES intervention was delivered by trained community members in the original curriculum and was delivered by certified teachers for YES-HR. Training and curriculum structure (see content modifications) were adjusted to accommodate for this personnel modification. In addition, the original YES intervention included partnerships with community adults to complete community change projects. As these partnerships were not feasible during the school day program due to logistics, including challenges with finding adult community partners available during the school day and engaging these adults, we modified the adult partners in YES-HR. The adult partners included primarily school leadership and other staff within the school who were accessible and available to assist with the community change projects. Yet, some parents and other family members assisted in more minor roles outside of school hours.

Content modifications

Removing elements

We omitted some activities that were applicable primarily to after-school programs (e.g., snack and relax time) as in the original YES curriculum. We also reduced the overall structure of the lessons as certified teachers, with the assistance of social work interns, were delivering the program instead of trained community members. Researchers have found that teachers, especially experienced teachers, prefer some flexibility to tailor program delivery to their teaching style and classroom [36,37].

Adding elements: new topical areas added for YES-HR

Our initial steps in the adaptation process raised several issues that were important to address in the YES-HR curriculum.

Building healthy relationships

One new issue addressed in YES-HR is developing a common language and understanding around personal values and boundaries as foundational building blocks for healthy relationships. This included reflecting on one’s own values around relationships, communicating about consent, critically examining gender stereotypes and how these influence relationships, and recognizing power differentials. As this intervention was focused on primary prevention of TDV and SV, we integrated new activities to address these foundational building blocks for healthy relationships.

Bystanders.

Bystanders are a critical aspect of effective TDV and SV prevention [38,39]. Bystander intervention content focused on supporting youth to develop skills and attitudes to be able to intervene in a situation that is, or may become, abusive among their peers, or to confront attitudes, jokes, or comments that support violence. Consequently, we integrated bystander-focused lessons and activities into the curriculum. The bystander activities built upon the foundational skills developed during the healthy relationship-focused lessons; specifically, students developed an understanding of the bystander role in preventing violence and effective strategies to take action when witnessing unhealthy behaviors.

Training

The format, structure, and length of the YES-HR training remained the same as the original YES training. Specific adaptations included adding a background on TDV/SV among early adolescents and replacing some original YES activities with new activities added to the curriculum in the practice segments of the training.

Fidelity: adherence and quality delivery

The fidelity dimension results from the first year of program delivery are as follows: adherence mean (M): 4.90, standard deviation (SD): 0.75, 1: low to 7: high; quality delivery M: 4.94, SD: 0.39. Field notes indicated that teachers experienced significant time and logistical challenges to completing all activities in the curriculum, consistent with the adherence score. In particular, classroom management posed a barrier to completing all lesson activities. In addition, teachers often experienced competing demands between facilitating lesson activities, such as assisting a student experiencing distress, anxiety, or other challenges. Field notes also indicated variation in the degree to which students were engaged in YES-HR lesson activities. Informal teacher feedback to the study staff also indicated that some of the experiential activities were challenging given the class sizes or space constraints and that activities that relied on homework assignments were rarely completed.

DISCUSSION

Effective TDV and SV prevention interventions are critical to improving the health and well-being of youth. Given interconnections across forms of violence, adapting multilevel, evidence-based youth violence-prevention programs guided by implementation science frameworks is a promising approach to reducing TDV/SV. The current project is an important step in accelerating research to practice translation for SV/TDV prevention among youth. It also provides an example of how adaptation frameworks used in implementation research may be applied to systematically guide adaptation of an EBI to address related emerging health issues. The current study is an innovative contribution to violence prevention as it applies theoretically informed D&I frameworks to accelerate the research-to-practice translation and advance SV and TDV.

We made several adaptations to the YES-HR intervention to address TDV/SV, including context and content modifications, and use Stirman et al.’s classification system [40] to guide our adaptation discussion. Among our contextual adaptations, we made changes to incorporate the intervention as part of an in-class curriculum/setting, with a focus on meeting state-specified educational standards and objectives versus an after-school program. We had to ensure that the curriculum aligned with state-level educational standards for, in this case, social studies. These included using historical examples relevant to the content of the curriculum, including the Bill of Rights and civil rights activism, as well as skills, including analyzing community data, persuasive communication about a public issue, and citizen involvement. When delivering programs as part of school curricula, other EBIs would need to consider such contextual modifications. We also had personnel changes, both in the personnel delivering the program (teachers) and the other adult partners (school staff). The personnel changes influenced some of the content changes, such as degree of structure, and process by which youth carried out the projects with adult partners. As contextual modifications were underrepresented in modifications documented by Stirman et al. (11% of total modifications), the current study extends this research to further document and explore the impact of such modifications.

We also made content modifications to address SV and TDV while maintaining the intervention core of positive youth development and empowerment approaches. These content modifications included not only adding and removing elements but also loosening the structure to better fit certified teachers and refining activities to meet the needs of the youth participating in the program. This is consistent with Stirman et al. [40]. who found that refining, adding, and removing elements were the most common content modifications.

Although training modifications were made while adapting YES to YES-HR, the modifications were not substantial. The training, as in the original YES, focused on the underlying theoretical/conceptual framework for the intervention and its approach (e.g., empowerment theory and positive youth development), risk and protective factors for violence, and practicing active learning activities. Addressing the adaptations to training, however, contributes to an underdeveloped area of adaptations in implementation science [35]. Following the initial YES-HR training, we found that additional modifications were needed to address the unique logistical and space challenges of delivering the curriculum as part of the school day, and the needs of students experiencing stress and trauma. We elaborate on these changes in the Lessons Learned.

Through the systematic adaptation process and documentation of adaptations, we found that YES curriculum is a suitable program to adapt for TDV/SV prevention. We also found that teachers generally delivered the program with moderate fidelity and that fidelity was influenced by curriculum structure and timing, logistical challenges, competing demands, and students’ needs. The challenges identified through the first program iteration provides critical practice-based evidence necessary to ensure that the intervention is not only effective but also implementable for broad dissemination. We used these data to inform refinement of YES-HR intervention for subsequent implementation.

Lessons learned: YES-HR refinement

We used the results from this initial implementation evaluation to inform further refinement of the YES-HR intervention for subsequent delivery to enhance implementability and support program sustainment.

Content modifications

Reduced the number of activities and sessions

Our field notes, fidelity ratings, and teacher feedback overwhelmingly suggested that the curriculum was too lengthy to be reasonably completed within the time allotted. Research staff and school partners may have overestimated what could be completed in a class period given classroom management challenges and disruptions, such as special school events, snow days, and professional development days. As a result, we reduced the total number of sessions and reduced the number of activities per session. Many of the activities that were removed were nonessential supplementary activities intended to reinforce the material, such as watching a video followed by a group discussion of the content. We removed redundant or nonessential activities that students did not like or respond to or that did not relate to their experience (e.g., videos on consent that were perceived as immature and did not generate discussion). To better meet the needs of teachers and their classroom contexts (number of students, room size, available technology, and classroom climate), we restructured the lessons so that they included one primary activity, with options for additional/alternate activity if time allowed. We also eliminated homework activities to ensure core activities were completed.

Tailoring: options for activities not suited to the context

While our field notes, as well as teacher feedback, indicated that many activities were engaging for students, the study team reviewed the curriculum replaced or revised activities that were received less favorably by students. The study team also updated the lessons to offer multiple (primary) activity options.

At least three formats were provided for the core activity in each session of the curriculum to support teachers to address learning objectives while also attending to the unique needs of their classroom, including physical space constraints, student behavior, level of student engagement, and other classroom dynamics.

For example, for a session focused on defining personal values, teachers had the option of having students either (a) complete a worksheet to identify their top three personal values from a list and describe why they identified those values; (b) complete a ball toss where each student named one of their personal values as they tossed the ball to the next student; (c) play a human bingo game, in which students initial shared values on one another’s bingo sheets; or (4) act out personal values in role-play vignettes in which each group is assigned a scenario and is guided to make a decision in the scenario based on the value they were assigned. The options provide the facilitator flexibility in terms of the amount of physical space, interactivity, and time to complete the activity, while still achieving the core objective to identify personal values.

Training

Classroom management: incorporated trauma-informed approaches

As teachers within the study schools frequently reported that their students disproportionately experienced stress and trauma, we revised the training and curriculum. An estimated 25% of youths in the general population have experienced a traumatic event as have 75% of youth involved with the juvenile justice system [41,42]. Many youths who experience traumatic life events demonstrate a reduced ability to manage stress and can be triggered by a variety of situations that subsequently elicit feelings of being emotionally or physically unsafe [42]. Hence, the school environment, and in this case, YES-HR activities hold the potential to be a stressor for some youth. Consequently, we included a new module specifically focused on trauma-informed approaches as part of the YES-HR training.

Given the sensitive nature of some of the YES-HR activities, the chance of potentially triggering an at-risk student, who had experienced or witnessed interpersonal trauma, called for teaching staff, social work interns, and those involved with the YES-HR curriculum rollout to interact with the youth from a trauma-informed lens; Substance Abuse and Mental Health Services Administration identifies six key principles of a trauma-informed approach that provide a framework that is generalizable across multiple contexts [43]. These six principles align, to a great extent, with empowerment theory (and aspects of Michigan’s eighth grade social studies curriculum), including safety, trustworthiness and transparency, peer support, collaboration and mutuality, and empowerment relative to voice and choice, as well as cultural, historical, and gender issues [43].

Limitations

The current study included three intervention schools and three control schools for a total of 20 classrooms in a disadvantaged community and our discussion focuses on the three intervention schools. These schools, however, may not be representative of all youth at risk for SV and TDV. Nevertheless, this study is an important first step in a theoretically guided adaptation of a violence-prevention curriculum. The quantitative fidelity measures were limited as we were not sufficiently powered to complete site-level analysis beyond descriptive data. These data, however, were a critical piece of our mixed-methods approach that complemented the qualitative results to provide a comprehensive analysis of implementation. Furthermore, these results informed a second iteration of the curriculum from lessons learned in Iteration 1 to further refine the adaptive elements of the intervention. Our feedback from teachers was informal. We received this feedback because of our developing relationships with them and our schools. Future feedback would benefit from more structured focus groups and/or semistructured interviews. Given resource and time constraints, we were not able to pilot test the full intervention prior to rollout. While this is consistent with challenges associated with delivering interventions in community settings, future pilot tests would benefit from pilot testing the full adapted intervention. Finally, the focus of the current paper is on describing a novel application of adaptation frameworks from implementation science to expand the scope of violence prevention for middle-school youth. A critical next step in this research will be to evaluate the effectiveness of this intervention through the investigation of individual-level student outcomes associated with violence and positive youth development.

We propose the following recommendations for the expanded application of adaptation frameworks to address focused, but related, outcomes of evidence-based violence-prevention interventions. First, a thorough understanding of the intervention’s theoretical underpinnings, proposed mechanisms of action, and core elements that contribute to its effectiveness is critical. Using this knowledge, researchers and practitioners can more reliably identify those core elements that contribute to the intervention’s success in achieving the desired outcomes. Second, using established D&I frameworks to guide systematic adaptation will support both flexibility and fidelity in program delivery. A multitude of adaptation frameworks exist [19], and these frameworks provide specific, often step-by-step guidance for enhancing the fit between the intervention, the context, and population needs. Third, adaptation will rarely be a one-time event and requires collaboration among multiple stakeholders. Adaptation is a process. Researchers, practitioners, and community members need to engage in careful evaluation of why, how, and when adaptation needs to occur by carefully studying the adaptation process and its effect on intervention effectiveness [11]. Using adaptation frameworks, such as that proposed by Stirman et al. [40], can aid in documenting, evaluating, and understanding the effects of EBI adaptations. Through the process of systematic EBI adaptation to expand the scope of health outcomes with similar underlying risk and protective factors, we increase the chances that the program addresses specific context and population needs to achieve outcomes.

Future research

Future research will include an assessment of the longitudinal outcomes of the intervention, including sustained behavioral and attitude change of youth, from 2 years of survey data collection following the end of participation in the YES-HR program. We will investigate differences between intervention and comparison schools as well as between the first and second iterations of the YES-HR curriculum. Further, the researchers intend to explore the implementation of YES-HR in other contexts, including differing geographic and cultural groups, or when offered as an elective course or after-school program instead of universal implementation.

CONCLUSIONS

Implementation science frameworks provide a useful guide to adapt the YES violence-prevention curriculum to adapt it for TDV/SV prevention and develop YES-HR. Our initial year of program implementation results indicate that teachers delivered the program with moderate fidelity and several barriers to effective delivery were identified. These data were useful in informing refinement of YES-HR to improve fidelity and, ultimately, program effectiveness. Using key steps from D&I frameworks supports developing a curriculum that is implementable with fidelity after researchers are gone. This initial adaptation and testing were a critical first step in accelerating research-to-practice translation through developing an intervention that is highly implementable, sustainable, and effective in reducing sexual and teen dating violence.

Funding

This research is supported by the Centers for Disease Prevention and Control (5U01CE002843; MPI: Dr. Kernsmith and Dr. Smith-Darden) and the National Institute on Drug Abuse (K01DA044279-01A1; PI: Dr. Eisman).

Compliance with Ethical Standards

Conflicts of Interest: The authors declare that they have no conflicts of interest.

Authors’ Contributions: All authors have approved the final manuscript and agree with its submission to Translational Behavioral Medicine. All authors have contributed to the scientific work and are responsible and accountable for the results. Special roles include principal investigators (P.D.K. and J.P.S.-D.).

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent: Informed consent was obtained from all individual participants included in the study.