Abstract
BACKGROUND: As few evidence-based behavioral interventions (EBBIs) are sustained in schools, their population health impact is limited. Incorporating implementation strategies can facilitate their sustainment. The Kids SIPsmartER intervention, which incorporates a robust implementation strategy bundle, has been implemented in 12 rural Appalachian middle schools since 2018. The trial design supported its maintenance after the initial Researcher-Led Year allowing for continued collection of implementation data. METHODS: This concurrent mixed method process evaluation included six data sources: fidelity checklists, teacher interviews and surveys, principal interviews and surveys, and researcher-maintained field notes. Included data came from each school's first and/or second Teacher-Led Years (i.e., after the Researcher-Led Year). Quantitative data were summarized using descriptive statistics. Summaries of schools' implementation experiences were developed from qualitative data sources and then content coded. RESULTS: Data from 24 teachers and 11 principals from all 12 schools were included. Of the 10 schools that completed their Researcher-Led year by Spring 2022, 9 (95%) maintained Kids SIPsmartER. 95% of teachers attended formal pre-implementation meetings. Teachers rated the various implementation strategies' helpfulness from 4.2 to 4.8 [5-point scale]. Teachers delivered 97% of expected lessons. Average fidelity among returned checklists was 94% (SD = 5.0%), which decreased to 66% (SD = 40%) when missing forms were counted as zeros. All continuing schools modified the delivery timeline. Some modified lessons. Rationales for delivery decisions reflected considerations to increase program fit. Multiple factors influenced teachers' and principals' perceptions of Kids SIPsmartER's fit, including compatibility with the larger curriculum, filling an instructional gap, and potential to impact students. Teachers and principals rated lesson content as important: 4.61 and 4.38 [5-point scale], respectively. Teachers also strongly agreed that their students engaged with the intervention [6.33, 7-point scale]. CONCLUSIONS: Study findings highlight the importance of incorporating and evaluating implementation strategies to ensure intervention fidelity and foster teacher motivation. Also, they stress the necessity of ensuring implementation strategies reduce school-level barriers and foster fidelity-consistent adaptations, teacher motivation, and intervention scalability. Together, findings have implications for the translation of Kids SIPsmartER and school-based EBBIs into practice, which could impact population health. TRIAL REGISTRATION: Clincialtrials.gov: NCT03740113. Registered 14 November 2018 - Retrospectively registered. https://clinicaltrials.gov/study/NCT03740113 .