How Can the Implementation of a Multicomponent Intervention for a Specific Population Inform Implementation Science?

Background: Youth with a history of maltreatment and foster care placement are at disproportionate risk for a host of mental health and behavior problems. Fostering Healthy Futures (FHF) is a preventive intervention designed to promote prosocial development in preadolescent children who have been maltreated and placed in foster care. The core components of FHF include 9 months of weekly skills groups and 1:1 mentoring provided by graduate students. FHF has been tested in two rigorous RCTs over the past decade and has been named an evidence-based program (EBP) by multiple registries. Once designated an EBP, community-based organizations expressed interest in implementing the program. There were questions, however, about possible adaptations, as FHF is a program with many detailed components.

Methods: Initially, FHF program developers conducted a “Core Elements Survey” with current and prior FHF staff to rank order the elements. This led to the development of a “Readiness Assessment” for agencies, which served to inform them of the non-negotiable program elements. Finally, program training and fidelity indices were developed. The program is currently being implemented through two community-based agencies, and despite the delineation of core elements before program implementation, there are frequent discussions of adaptation, even of these core elements, to meet contextual needs.

Results: Despite ongoing decision-making regarding what adaptations are acceptable when implementing FHF with fidelity, community-based implementations of FHF are evidencing high rates of program uptake and acceptability (comparable to those achieved in the trials). Results from the first two years of implementation include: 94% of children participated for the full year; 92% of skills groups were attended; 99% of core FHF skills group content was delivered; children received 2.5 hours of mentoring per week on average; 87% of children reported “FHF has helped me manage my feelings”; and 100% of children reported they were “glad they chose to participate in FHF.”

Implications: Many interventions that seek to reduce health disparities are complicated, and implementation efforts have struggled to find the balance between fidelity to the original model and sensitive adaptations that do not diminish the effectiveness. FHF will be used as a case example of how the success of flexibly implementing a multicomponent intervention while maintaining fidelity can inform the field. The discussion will address: funding prevention efforts, intervening with a highly mobile population that has multiple service sector involvement, training of providers in an intervention that is inherently flexible (i.e., mentoring), enhancing client engagement, and avoiding the voltage drop in outcomes.