Understanding High Quality Implementation over Three Years of It's Your Game, Keep It Real in South Carolina

Background: Quality implementation of health promotion programs is associated with better outcomes for participants, and understanding factors that contribute to quality implementation increases the likelihood that disseminated programs reach their intended goals.  The current study examined factors associated with high quality implementation across three years in an evidence-based teen pregnancy prevention program that included information about abstinence and contraception in 13 rural middle schools in South Carolina. Adolescents in this state face a disproportionate burden of teen pregnancy and STD rates, and teen pregnancy rates tend to be particularly high among rural  and African American youth  High quality is  demonstrated by 100% implementation of all lessons, 99% implementation of lesson activities, and mean student attendance of 11 out of 12 lessons per year.  In addition, the mean quality rating by independent observers was consistently high.

Methods: Quantitative data were collected on eight individual, organizational, and community/external-level factors associated with quality implementation through a survey of site coordinators and program facilitators at three points in time.  Factors included Facilitator Characteristics, Monitoring and Support of program implementation, Compatibility with school (e.g., culture, needs), Innovation Characteristics (e.g., improvement on current offerings), Resources, School-based Leadership, District Support, and External Environment (e.g., community support).  Additional contextual information from a semi-structured interview with a program staff person, technical assistance logs, and print media reports were collected and analyzed for key themes. 

Results:  The score for the factor Monitoring and Support was consistently high across all three years of implementation, and the score for the factor Resources was relatively low compared to other factors.  The combined factor score (average of all eight factor scores) increased or remained stable for more than half of all schools over three years of implementation. Schools with the largest changes in their combined factor scores also experienced changes in the school environment, such as changes in leadership and/or increased capacity among facilitators. However, all schools had relatively high scores on almost all factors.  

Conclusions:   One important result from this study is that in this high quality implementation study, all aspects of implementation fidelity were present to some extent.  Achieving the high quality implementation seen in this study reflects support at the individual-, school-, and community-level across all three years.