Intervention Fidelity in Research With Homeless Youths

Purpose: Homelessness is a complex social and global challenge (Mabhala, Yohannes, & Griffith, 2017; Perreault, Jaimes, Rabouin, White, & Milton, 2013). Although social conditions and programs vary from country to country, homeless youth are particularly vulnerable to many adverse health outcomes, a vulnerability that increases the longer they remain homeless. Despite this vulnerability, these youths also have many inherent strengths and positive attributes that are not acknowledged in most studies of this population (Rew, Powell, Brown, Becker, & Slesnick, 2016). Homeless youths have been recognized for their strength of character, hope for the future, connectedness, and resilience (Crawford et al., 2014). Those who have received support and resources from social service agencies report improvements in their life satisfaction (Heinze, 2013). Nursing interventions that focus on strengths and resources are needed to create a clearer and more holistic view of homeless youths. Moreover, such interventions must be developed and delivered with close attention to intervention fidelity, particularly when delivered in multiple community-based sites (Rew, Banner, Johnson, & Slesnick, 2018).The National Institutes of Health Behavior Change Consortium (BCC) identified five aspects of intervention fidelity: (1) study design, (2) provider training, (3) intervention delivery, (4) intervention receipt, and (5) enactment of intervention skills (Bellg et al., 2004). Implementing and maintaining principles of intervention fidelity are critical when developing and delivering community-based interventions, particularly to specialized populations such as homeless youths (Rew, Banner, Johnson, & Slesnick, 2017). In particular, intervention facilitator training must be consistent and ongoing, especially when an intervention is delivered in multiple sites by facilitators from multiple disciplines simultaneously.The purpose of this study was to describe the perceptions of intervention fidelity among intervention facilitators from a variety of disciplinary backgrounds who provided a brief intervention to homeless youths in an ongoing longitudinal study. The intervention is being tested simultaneously in two sites: Austin, Texas and Columbus, Ohio.

Methods:

Following institutional ethics board approvals at both sites and informed consent from the intervention facilitators, participants completed a short demographic form and answered open-ended questions that were analyzed using qualitative content analysis procedures. The focus of the questions was on the intervention facilitators’ perceptions of structural and personal factors that facilitated or hindered their attention to intervention fidelity.

Results:

Eight Graduate Research Assistants (GRAs) who were employed as intervention facilitators from two universities participated in the study. Three were females, 5 were males, 7 were White and 1 was Hispanic, 6 were single and the other 2 were married. These GRAs, whose mean age was 33.5 years, were employed for an average of 9.2 months (range 3-18 months) and provided interventions to an average of 10.9 youths (range 2 – 23 youths). Overall, the GRAs found it relatively easy to maintain intervention fidelity throughout the intervention, particularly the more experienced they became with the intervention over time. Structural factorsthat facilitated their adherence tofidelity included delivering the intervention in a place where the homeless youths felt safe, following the fidelity checklists, talking with peer GRAs, and listening to tapes of previous sessions. Personal factors that facilitated theiradherence to fidelity included following a self-prepared script, developing and maintaining relationships with drop-in staff, educational background, understanding of intervention fidelity, caring, ethics of justice, having a child of same age as homeless youths, seeing the content from the client’s perspective, friendliness, sitting in on someone else’s session, and reviewing the materials.

Structural factors that hinderedthe facilitators from maintaining intervention fidelity included the length of time allowed for each module of the intervention, problems with study participants not returning for subsequent modules, participants ending up in jail or being hospitalized, slides being out of order or not matching the fidelity checklists, or lack of management in the drop-in centers. Personal factors that hinderedthe facilitators from maintaining fidelity included being unable to develop rapport with a participant, allowing too much time off-script to develop rapport, and in one case, gender of client v. facilitator. Strategiesthat would have helped them to be more consistent in providing the intervention included having a more distinct script for the intervention rather than a mere outline, and having more time for role-playing the intervention before enactment.

Conclusion: These are new findings concerning intervention fidelity and point to the importance of following the NIH guidelines for intervention fidelity. When an intervention protocol is clearly identified, it is relatively easy for a variety of intervention facilitators to deliver the intervention as intended. Nevertheless, there are both structural and personal factors that can facilitate or hinder the facilitator’s ability to follow the intervention process and content 100% of the time. Findings from this study can be used to continuously improve the delivery of the intervention throughout the remainder of the study and as lessons learned when proposing a new intervention proposal.