Anita P. Barbee, MSSW, Ph.D. Becky Antle , MSSW, Ph.D. Kent School of Social Work

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What Evaluating Evidence Based Training Curricula Can Teach Us about Evaluating Child Welfare Training. Anita P. Barbee, MSSW, Ph.D. Becky Antle , MSSW, Ph.D. Kent School of Social Work University of Louisville NHSTES in Pittsburg, PA May 22, 2013. - PowerPoint PPT Presentation

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What Evaluating Evidence Based Training Curricula Can Teach Us about Evaluating Child Welfare Training

What Evaluating Evidence Based Training Curricula Can Teach Us about Evaluating Child Welfare Training

Anita P. Barbee, MSSW, Ph.D.Becky Antle, MSSW, Ph.D.Kent School of Social WorkUniversity of LouisvilleNHSTES in Pittsburg, PAMay 22, 2013

Louisville Child Welfare Training Evaluation Model (Antle, Barbee & van Zyl, 2008)Zooming in on the Training CycleWe have mostly focused on individual and organizational predictor variables effecting training outcomes of satisfaction, learning, transfer of learning and organizational and client outcomesWe continue to measure all of those aspects of training, but when we had the opportunity to conduct efficacy trials to test evidence informed and evidence based training interventions we began to focus more on the training cycleWhich Slides Contain Background Information and Which Are the FocusThe next slides in your handout are background information about two grants that allowed us to test the efficacy of several EITs and EBTs (Within My Reach, Love Notes and Reducing the Risk) (slides 5-11)We will focus our talk on how to measure fidelity to the training curriculum, trainer competence and two training variables that we are finding impact outcomes (trainer alliance and group cohesion) and will give you all copies of our measures (slide 12)Finally slides 13-22 give findings from one analysis- these are for future reference- we can summarize quicklyWe will end our time leading a discussion about implications of that analysis (slides 23-30) and how we can transfer these findings to child welfare training evaluation- (slide 31)

First Grant that Evaluated Efficacy of Evidence Based or Evidence Informed CurriculaWe received $2.5M in funding from the Office of Family Assistance (OFA) for the grant Relationship Education Across Louisville (REAL) from 2006-2011 which evaluated the efficacy of Within My Reach in lowering Interpersonal Violence (IPV) in a population of 900 low income adults served by Neighborhood Places in Louisville KY as well as the efficacy of Love Notes on 450 youth who had dropped out of high school in Louisville KY (Antle was PI, Barbee was Evaluator)Second GrantWe received $4.8M in funding from the Office of Adolescent Health (OAH) for a teen pregnancy prevention research study we call CHAMPS (Creating Healthy Adolescents Through Meaningful Prevention Services) from 2010-2015. It is a three arm randomized controlled trial and longitudinal study comparing the effects of three training interventions. 1300 urban, refugee and foster youth ages 14-19 are being randomly assigned to either Love Notes, Reducing the Risk or The Power of We (that serves as a control condition) and followed at the 3, 6, 12 and 24 month points. These trainings are delivered in 20 community based organizations serving high risk youth in Louisville, KY (Barbee is PI, Antle is Co-PI).

Training Interventions: Within My ReachWithin My Reach (Pearson, Stanley, & Kline, 2005) is a 16 hour healthy relationships program, a relationship education intervention designed for low-income populations that teaches communication and conflict resolution skills, relationship decision making strategies, and relationship safety/violence prevention content. The WMR program has many modules that promote group interaction via discussions, activities, and processing of topics as they relate to the participants lives. The WMR program promotes group interaction and has several group based activities wherein group members share parts of their lives. For more information about WMR see Antle et al. (2011) and Pearson et al. (2005). This program was provided in four 4-hour sessions (typically conducted weekly) at neighborhood-based social service sites.WMR was developed to reach a broader audience (individuals who may or may not be in a romantic relationship) than couple-focused relationship education programs. Specifically, the WMR curriculum was designed for individuals (vs couples) in order to be a primary prevention method (e.g., assist individuals in making sound relationship choices, regardless of relationship status) as well as to safe-guard participants when sensitive issues are discussed, in particular, intimate partner violence (wherein including both partners in the session may be contraindicated).

Love NotesLove Notes, was developed to educate participants about healthy relationships, including issues of decision-making, communication and conflict resolution, and overall safety, including the prevention of pregnancy and sexually transmitted disease (Pearson, 2009). This strategy may provide more long-term prevention of interpersonal violence, as participants are engaged in a thorough self-assessment of relationship values, needs, and models of safety that will assist them with future decision-making and commitment in intimate relationships. Love Notes is a derivative of the Prevention and Relationship Enhancement Program (PREP; Stanley, Markman, & Jenkins, 2009), which is relationship marriage education program listed as an evidence-based practice (EBP) by SAMSHA (www.samhsa.gov). This curriculum builds on social exchange theory and meets the needs of youth who are alienated and in need of loving personal relationships. Thus, it is an excellent counterpart to the pregnancy prevention curriculum and allows a test of theoretical model on what combination of information is best in preventing high risk behaviors, pregnancy and transmission of STIs. Research by Antle et al (2011) found that participants in Love Notes experience significant gains in relationship knowledge, communication and conflict resolution skills, relationship self-efficacy and attitudes toward violence.

Reducing the RiskReducing the Risk: Building Skills to Prevent Pregnancy, STD and HIV (RtR) was developed by Richard Barth, MSW, Ph.D. in California. The training manual is in its 5th Edition and was last published in 2011. This curriculum is one of the first that was evaluated using an experimental design, with a longitudinal follow up (6 months and 18 months) and tested on a large group of high school students (N = 758). It is also one of the first programs to show an impact on beliefs of adolescent sexual behavior prevalence and actual behavior as well as increasing parent-child communication about abstinence and contraception (Kirby, Barth, Leland, and Fetro, 1991). For those who were virgins at the pre-test, the curriculum significantly reduced the onset of intercourse at 18 months and those who did have sex were more likely than controls to use contraceptives. These effects held for members of several ethnic groups (Caucasian, African American, Hispanic and Asian), both genders, and for lower and higher risk youth. For females and lower-risk groups who had initiated intercourse before the pre-test and curriculum delivery, contraceptive use was increased after the training and significantly more so than for controls (Kirby, et al 1991). The youth in the comparison group did receive a traditional sexuality education intervention, thus for RtR to significantly improve outcomes for participants above and beyond another intervention means that it is particularly effective.

RtR continuedAnother study that tested the effectiveness of RtR was conducted in Arkansas with rural and urban youth (Hubbard, Giese and Raney, 1998). This study found that RtR delayed the initiation of sex among youth who were virgins at the pre-test and increased condom use among youth that did initiate intercourse after the training. A third study evaluated the impact of RtR in Kentucky and Ohio (Zimmerman, et al, 2008). It found that RtR significantly delayed the initiation of sex, but condom and contraception use was not increased.

The Power of We (POW)The control group participants receive training in community organizing and community building that is delivered by trainers from the Network Center for Community Change (NC3), a nonprofit organization in Louisville. This ensures that participants are receiving some service and filling the same number of hours (approximately 13) interacting in a training environment, just on a different and unrelated topic.

Measurement Issues When Using Evidence Based or Evidence Informed CurriculaBecause of the importance of testing the efficacy of evidence based curricula on outcomes, we placed special emphasis in our evaluation on measuring and ensuring fidelity to the curricula using a special tool and objective evaluators who observed each training session and rated fidelity to the curriculum.For CHAMPS we have also included a quantitative measure of facilitator engagement which is completed by each facilitator about their own performance, their partners performance and which is completed by the objective evaluator about each facilitators performance.For a portion of the REAL grant and all of the CHAMPS grants we have included measures of facilitator engagement and group cohesion along with our usual measures of participant satisfaction.

One Example of Effects of Fidelity, Engagement and Group Cohesion on Outcomes in WMR TrainingA sample of 126 participants98 women21 men 7 unknown genderAverage Age was 33.33 years (s.d. = 12 years)Average number of children was 2Median education level was high school or GEDRacial background of participants66.1% African American27.8% Euro American 6% Hispanic, Asian American or other

Measure of FidelityAdherence to the program was monitored each session by trained raters. Adherence to the WMR training manual was generally high (i.e., 94% of the proposed material, including discussions, activities, and content were covered). We can argue that those training participants that participated in all 4 training days (92% of participants) received a full dose of the intervention given attendance and fidelity to the curriculum by facilitators.

Effects of Adherence on OutcomesWe conducted one analysis on 559 participants in WMR and found a significant interaction between adherence, participant reactions to the training, and relational outcomes (communication skills and couple relationship quality).For participants who reported very positive reactions to the training, there was a negative effect of strict adherence on relational outcomes. Moderate adherence to the curriculum allows for more discussion and interactions with the trainer and other participants, which is likely more desirable when participants have a very positive view of the facilitator and the training.In contrast, for participants who reported less favorable reactions to the training, there was a positive effect of strict adherence on relational outcomes.This suggests that in a situation where a trainer was viewed as less competent or engaging, it was better for participants when he/she followed the curriculum content very precisely. This finding actually goes beyond Barber et al. (2006) who found no effect of adherence on outcomes when clients are engaged to suggest a negative effect of adherence on outcomes when participants are otherwise engaged or satisfied with services.

How We Analyzed the Impact of Adherence on OutcomesMultilevel modeling was utilized to test the hypotheses (time nested within participants, nested within groups). At level 1, we included the repeated measures for the relational outcomes (i.e., the dependent variables, DAS and CPQ at pre, post, and 6-month). The Time variable was coded -2 = pre, -1 = post, and 0 = 6-month follow-up, thus, the intercept values reflect participants scores at 6-month follow-up. At level 2 or the participant level, we included sex and race/ethnicity (both uncentered) as control variables and participants reactions to the program at post (grand-mean centered). At level 3 or the group level, we included ratings of adherence (grand mean centered for both the linear and quadratic effects). We created two models, one for each outcome variable (i.e., DAS and CPQ). We examined whether participants outcomes would be associated with adherence (both linear and quadratic effects), participants reactions to the program, after controlling for sex (Men = 1, Women = 0) and race (White = 1, Racial/Ethnic Minority = 0). We also included the cross-level interaction between participants reactions and adherence on the intercept.

Facilitator Working Alliance with ParticipantsWorking Alliance Inventory-Short Form (WAI-S, Tracey & Kokotovic, 1989). The WAI-S is a client rated measure of working alliance that consists of 12 items that assess goals and tasks for therapy as well as the relational bond between the client and therapist. These items were rated on a seven-point scale ranging from 1 (Strongly Disagree) to 7 (Strongly Agree) with higher scores indicating a better working allianceThe WAI-S is a commonly used measure of working alliance and the reliability and validity has been demonstrated in numerous studies comparing the WAI-S to other working alliance scales and therapy outcomes (see Horvath et al., 2011 for a review). The language was adjusted to reflect the premarital education context, consistent with Owen et al. (2011). Some couples took premarital education with two leaders; working alliance scores for the two leaders were highly correlated (r = .78), so we used an average of the scores in our analyses. This measure was completed at post intervention and the Cronbach alpha was .85.

Group Cohesion of ParticipantsGroup Climate Questionnaire (GCQ; MacKenzie, 1983). The GCQ has 12 items that are rated on a 7-point Likert scale, ranging from 0 (not at all) to 6 (extremely). The GCQ assesses group members perceptions of the group environment. The GCQ has three empirically based factors: a) Engagement or the degree of self-disclosure, involvement, and investment among group members(b) Avoidance or the lack of addressing key issues between members or avoidance of responsibility to change(c) Conflict- which captures the overt struggles and covert sense of distrust among group members (MacKenzie, 1983). Support for the internal consistency of the GCQ has been shown in previous studies (e.g., alpha = .88 to .94; Kivlighan & Goldfine, 1991; MacKenzie, 1983). Construct validity of the GCQ has been demonstrated by its relationship with therapy outcomes, therapist ratings of the group process, and other client rated group process measures (e.g., Kivlighan & Goldfine, 1991; Quirk, Miller, Duncan, & Owen, in press). In the current study, the Cronbach alphas for the three subscales were .77 (Engagement, five items), .84 (Conflict, four items), and .56 (Avoidance, three items). Similar to the WAI, this measure was only completed at post intervention.

Outcome Measure: Relationship ConfidenceRelationship Confidence. We used the 5-item Confidence Scale (Stanley, Hoyer, & Trathen, 1994) to measure couples confidence that they can effectively manage t...

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