National Implementation of FOYC+CImPACT in the Bahamas: implementation strategies and improved outcomes.

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Project Summary/Abstract Over the past two decades, the Bahamian Ministries of Education (MOE) and Health (MOH) and our research team have adapted a CDC “Best Evidence” HIV Prevention Program to produce the “Focus on Youth in the Caribbean (FOYC) and Caribbean Informed Parents and Children Together” (CImPACT) risk reduction program to address the HIV epidemic in The Bahamas. Two randomized, controlled longitudinal trials of FOYC and FOYC+CImPACT found the programs to be effective in improving knowledge, condom-use skills and/or self-reported risk behaviors. In 2010 the MOE decided to include FOYC (logistically less complex than FOYC+CImPACT) in the government grade-6 curriculum nationwide, with boosters in grades-7 and -8. The MOE now plans to expand the offering to the more effective but logistically more complex FOYC+ CImPACT version. The MOE, MOH and our research team examined factors associated with fidelity of teaching FOYC among 283 teachers, and the relationship between fidelity of teaching with student outcomes among 4,411 students. Teachers taught slightly over 50% of FOYC's core activities. Evaluations indicate that students taught by “low-performing” teachers exhibited poorer outcomes in HIV/AIDS knowledge, condom-use skills, self- efficacy, and intentions; the reverse was true for students of “high-performing” teachers. Screening instruments and tracking processes to identify teachers at risk of low implementation, and evidence-based implementation support and remediation programs have been identified/developed for use throughout implementation. Biweekly “real-time” data-gathering and analysis to inform ongoing decision-making about adjustments or changes to be made to the implementation plan of FOYC+CImPACT by the MOE and MOH are the focus of this proposal. A Bahamian-specific adaptation of communities of practice (CoP), implementation monitoring and feedback, and innovative training are strategies to enhance teachers' implementation. The proposed research addresses three hypotheses of public health importance: 1. A more intensive training and supervision program for at-risk or moderate-performing teachers will enhance their implementation fidelity to the average level of the high-performing group (85%); 2. An HIV-prevention program delivered at the national level can be a) implemented with fidelity (delivering >85% of core activities in both FOYC and CImPACT consistent with that described by the developers) in grade-6; and, b) sustained over time (monitored annually); and, 3. Student outcomes (knowledge, reproductive health skills, perceptions and self-reported behaviors) will: a) continue to be highly correlated with implementation fidelity; and, b) be sustained over time (assessed annually through grade 9). We aim to determine if the provision of either or both a) biweekly monitoring, feedback and support through a “community of practice” to at-risk and moderate-performing teachers; and b) an enhanced decision-making platform by the MOE and MOH based on the real-time implementation data will: 1) increase national implementation fidelity; and 2) result in sustained implementation over time.