Implementing the LifeSkills Training drug prevention program: factors related to implementation fidelity
Implementing the LifeSkills Training drug prevention program: factors related to implementation fidelity
Sharon F Mihalic 1
Abigail A Fagan 0
Susanne Argamaso 1
0 Dept. of Criminology and Criminal Justice, University of South Carolina , Columbia, SC , USA
1 Institute of Behavioral Science, University of Colorado , Boulder, CO , USA
Background: Widespread replication of effective prevention programs is unlikely to affect the incidence of adolescent delinquency, violent crime, and substance use until the quality of implementation of these programs by community-based organizations can be assured. Methods: This paper presents the results of a process evaluation employing qualitative and quantitative methods to assess the extent to which 432 schools in 105 sites implemented the LifeSkills Training (LST) drug prevention program with fidelity. Regression analysis was used to examine factors influencing four dimensions of fidelity: adherence, dosage, quality of delivery, and student responsiveness. Results: Although most sites faced common barriers, such as finding room in the school schedule for the program, gaining full support from key participants (i.e., site coordinators, principals, and LST teachers), ensuring teacher participation in training workshops, and classroom management difficulties, most schools involved in the project implemented LST with very high levels of fidelity. Across sites, 86% of program objectives and activities required in the three-year curriculum were delivered to students. Moreover, teachers were observed using all four recommended teaching practices, and 71% of instructors taught all the required LST lessons. Multivariate analyses found that highly rated LST program characteristics and better student behavior were significantly related to a greater proportion of material taught by teachers (adherence). Instructors who rated the LST program characteristics as ideal were more likely to teach all lessons (dosage). Student behavior and use of interactive teaching techniques (quality of delivery) were positively related. No variables were related to student participation (student responsiveness). Conclusion: Although difficult, high implementation fidelity by community-based organizations can be achieved. This study suggests some important factors that organizations should consider to ensure fidelity, such as selecting programs with features that minimize complexity while maximizing flexibility. Time constraints in the classroom should be considered when choosing a program. Student behavior also influences program delivery, so schools should train teachers in the use of classroom management skills. This project involved comprehensive program monitoring and technical assistance that likely facilitated the identification and resolution of problems and contributed to the overall high quality of implementation. Schools should recognize the importance of training and technical assistance to ensure quality program delivery.
The recent focus of school-based delinquency prevention
efforts has been to identify and replicate effective
researchbased programs, i.e., programs that have been tested
rigorously and achieved positive results in the prevention or
reduction of delinquent behavior and substance use.
Several programs have emerged as exemplary in meeting
these criteria, and have been placed on government and
private agency "what works" lists for entities seeking to
implement evidence-based programs [1-6]. Once an
organization chooses a model program, it expects to
achieve outcomes similar to those found in research trials,
contingent upon being able to implement the program
with integrity to the designed model.
What is missing from this formula, and what has become
increasingly more important in prevention research [7-9],
is how model programs go from package to process, and
how to ensure that these effective programs, once
immersed in "real world" settings, are implemented as
intended. Although a growing area of study, program
"integrity" or "fidelity" including adherence to critical
components, methods of delivery, and program dosage
has been relatively neglected in the prevention research
literature [10-13]. Particularly lacking are studies that
describe how well programs are implemented, as well as
what factors inhibit or promote implementation with
Implementation fidelity of school-based prevention
Schools are an ideal environment for widespread
dissemination of successful delinquency prevention programs
because they contain a universal target population and
valuable program facilitators (i.e., teachers who are
already employed by the schools who will only need
training in the specific program protocols). As a result,
many program developers have designed and tested
prevention programs that take place in school settings, and
many of these programs have demonstrated evidence of
positive outcomes for students [18-20].
While schools now have more choices regarding
evidencebased programs that meet their needs, successful
implementation of a given program is not guaranteed. For
example, the National Study of Delinquency Prevention
in Schools demonstrated great variability in the
implementation of school-based prevention programs, with
prevention activities often not implemented with
sufficient strength and fidelity to produce a measurable
difference in the desired outcomes . In this study, only
onehalf of drug prevention curricula and one-fourth of
mentoring programs met dosage requirements because
schools offered fewer and less frequent sessions than were
specified by program developers. Moreover, only one-half
of the programs were taught in accordance with the
recommended methods of instruction. One national
assessment of school-based prevention programming also
demonstrated significant deviations in program
implementation, with schools frequently operating with
untrained teachers, without the required materials, and
with misspecification of the population to be served (e.g.,
targeting high-risk students with universal programs)
. Only 19% of all school districts surveyed faithfully
implemented effective prevention curricula.
These findings contrast with research trials that reported
high rates of implementation fidelity [23-28]. For
example, a program evaluation of the LifeSkills Training (LST)
program demonstrated that instructors taught an average
of two-thirds (68%) of the program objectives .
Likewise, an evaluation of the Early Alliance program
demonstrated that program staff taught an average of 80% of the
required material .
The less successful results found in community-based
replications suggest that variability in fidelity increases when
programs are widely disseminated [29,30]. When
implementation suffers, communities are less likely to achieve
the anticipated benefits of the program. While there is
tension between those who promote strict adherence to
program fidelity and those who promote local adaptation,
our own emphasis is on maximizing fidelity. There is
strong evidence that some programs only work when
implemented with a high degree of fidelity, and other
research suggests that closer adherence to core
components results in stronger participant outcomes
[23,28,3136]. Proponents of adaptation have a tendency to
substitute program sustainability for program effectiveness as
the outcome criteria. Local adaptation may well increase
the likelihood of sustaining a program, but if it renders
the program ineffective, this is not a desirable outcome.
Both fidelity and sustainability are necessary to an
effective prevention effort .
Factors promoting implementation fidelity
As programs become more widely disseminated, the need
to identify factors promoting or inhibiting
implementation quality becomes essential. Much of this research has
been exploratory, typically based on process evaluations
and qualitative evidence . Nonetheless, several factors
have been identified as associated with implementation
fidelity, including in-depth training for program
implementers, strong support from key participants,
characteristics of the program itself, and comprehensive
Staff training is critical for success because it provides the
knowledge and skills needed to implement the program,
fosters support and commitment to the program, and
communicates the importance of program fidelity
. Booster training sessions can help ensure continued
program involvement, rekindle commitment where
needed, and ensure that implementers are continuing to
deliver the program elements with fidelity [39,43].
Studies have demonstrated a relationship between teacher
training and greater implementation fidelity [38,44,45]
and better student outcomes [46-48].
It is essential that program staff at all levels of
implementation provide strong support for a newly chosen
program. At the top level, the project director or coordinator
champions the program replication from its inception
and throughout implementation. Program fidelity is
strongly influenced by the commitment displayed by the
site coordinator, who advocates for the program, ensures
that program protocols are in place, and identifies and
helps resolve implementation problems [39,40,49-51].
School administrators also must back the program, and
agree to adopt the initiative, make needed resources
available, garner initial staff "buy-in" to the values and ideals
of the program, and exert strong, continuous pressure for
implementation [40,43,51]. Success or failure of
schoolbased programs may ultimately rest with its teachers. In
order to support a program that utilizes valuable class
time, teachers must believe the program is worthwhile,
have a sense of ownership for it, encourage
implementation by others, and feel supported by school
Specific program characteristics also can influence the
quality of implementation. Program complexity and
structure have been associated with successful delivery;
programs with clear goals and procedures are easier to
implement and less likely to result in deviation
[40,49,52,53]. A set curriculum with activities that are
viewed as relevant, attractive, and easy to use also
enhances program adoption, helps provide a clear
program structure, and may reduce deviations from the
intended content [42,48]. Integration into the school
system, particularly finding a regular class for programming,
is important for adoption, implementation, and
Finally, ongoing and rigorous program oversight is
associated with implementation fidelity [25,28,32,54,55]. An
evaluation of the Early Alliance program attributed high
levels of implementation adherence to program
monitoring protocols, which included intensive staff training,
implementers' self-reports of content taught each session,
weekly staff supervision, and other technical assistance
from research staff . In contrast, an evaluation of the
Multisystemic Therapy (MST) model indicated more
program drift and greater therapist variability when standard
weekly feedback from MST consultants was eliminated
. Likewise, an attempt to disseminate the LST program
in Kentucky reported that only one-half of teachers who
received training later taught lessons, which the authors
attributed to a lack of oversight by state and local school
In summary, prior literature has described mixed evidence
regarding the extent of implementation fidelity of
schoolbased prevention curricula, with some research trials
documenting high levels of implementation fidelity, and
community-based replications typically achieving far less
success. Though some factors related to implementation
quality have been identified, very little is known regarding
how program activities actually take place during
replications, what specific challenges are faced, and how these
problems can be overcome . These are all relevant
issues for communities interested in replicating
evidencebased programs, and more information can help guide
future efforts and increase the likelihood that
communities will satisfy program requirements.
The Blueprints Initiative, funded by the Office of Juvenile
Justice and Delinquency Prevention, U.S. Department of
Justice, was designed to accomplish these goals .
Blueprints model programs have been held to the highest
standard of scientific testing and controlled program
replication, and the Blueprints Initiative examined how these
programs were replicated in multiple, naturalistic settings.
Earlier findings identified factors likely to relate to
implementation fidelity, including program support and
commitment among administrative and implementing staff,
training and technical assistance, specific elements of the
program itself, and characteristics of the adopting
The current paper expands upon earlier published
findings regarding the process evaluation of one model
program, the LST school-based drug prevention curriculum
. The previous results were based upon replication of
LST in 70 sites (292 schools) across the United States.
Primarily descriptive data were analyzed in order to
determine the extent to which schools replicated the LST
curriculum with strong adherence to the model, identify
problems faced during implementation, and describe the
steps taken to overcome these challenges. After two years
of implementation, teachers were observed to have taught
8186% of the required LST objectives and activities.
Implementation factors that were significantly correlated
with higher rates of implementation fidelity included the
support and ability of the local coordinator and
observations that teachers spent much time using didactic
instruction (though this measure was also correlated with worse
student behavior and less student participation in
lessons). Variables significantly related to teaching all the
lessons (i.e., program dosage) included teachers' overall
rating of the program and quality of the materials.
The current paper summarizes results from the complete
LST replication project. We describe implementation
outcomes for the full sample of 105 sites (432 schools) after
replication of the entire three-year curriculum in all sites.
In addition to providing a descriptive analysis of
implementation fidelity results (including challenges faced and
overcome), we use multivariate analysis to demonstrate
predictors of four primary elements of implementation
fidelity (adherence, dosage, quality of delivery, and
participant responsiveness). Four research questions are
1) Did the LST program reach the intended, universal
population of middle school students?
2) To what extent was the program implemented with fidelity; i.e., covering the majority of information and activities in each lesson, delivering all the lessons, using varied teaching techniques, and engaging participants?
3) What factors were associated with these four aspects of implementation fidelity?
4) What obstacles and barriers were encountered during implementation, and how were they addressed?
The LifeSkills Training initiative
The LST process evaluation was conducted by Blueprints
project staff at the Center for the Study and Prevention of
Violence (CSPV), located at the University of Colorado.
CSPV's primary goal is integrate prevention research and
practice. The "hallmark" project of CSPV has been the
Blueprints for Violence Prevention Initiative, an effort to
identify and promote the implementation of exemplary
evidence-based programs. National Health Promotion
Associates (NHPA), Inc, the providers of the LST
curriculum, and their cadre of certified LST trainers, were
contracted to provide training and technical assistance to
implementation sites. Site selection occurred from 1999
to 2001, with the final sample including 105 sites and 432
schools. Sites were comprised of one to 24 schools, and
sometimes included multiple school districts. Sites were
located in urban, suburban, and rural areas and served
students of varying socioeconomic status and
racial/ethnic backgrounds. (See Additional File 1 for more
information regarding sites and schools participating in the
The LST program is a school-based, universal program
designed to prevent tobacco, alcohol, and other drug use
among middle and junior high school students. Research
trials have demonstrated that the program reduces
tobacco, alcohol, and marijuana use up to 80%, with
effects sustained through high school and demonstrated
for adolescents of varying socioeconomic status and race/
ethnicity . The three-year program includes
self-management skills (e.g., decision-making, coping with
anxiety), social skills (e.g., communication, assertiveness),
and information relating to drug use (e.g., consequences
of drug use, drug resistance skills). Lessons are generally
taught by classroom teachers using a variety of teaching
techniques, including didactic instruction, classroom
discussion, behavior skill rehearsals, and demonstration of
Schools participating in the Blueprints Initiative did not
receive monetary incentives to replicate LST, but were
provided with all curriculum materials, training and technical
assistance needed to implement the curriculum. Thus,
participating schools were able to provide LST to all
eligible students with no direct costs (other than staffing) to
the school district. In exchange, schools were required to
implement the full three-year curriculum. The first year
(level one) included 15 lessons to be taught to all sixth- or
seventh-grade students, one to five times per week in at
least 50-minute class periods. In the second year of
implementation, these students were to receive ten booster
sessions (level two), while an incoming cohort of sixth- or
seventh-grade students would receive the level one
curriculum. In the third year of implementation, eighth- or
ninth-grade students received five booster sessions (level
three), seventh- or eighth-grade students received the level
two curriculum, and an incoming cohort of sixth- or
seventh-grade students received the level one curriculum.
During the research project, violence prevention lessons
(three lessons in level one, two in level two, and four in
level three) were added to the packaged curriculum. As
NHPA considered these lessons optional, and schools had
not previously committed to teaching them, the lessons
were not required from Blueprints sites.
Sites responded to a Request for Proposal (RFP) issued by
the Office of Juvenile Justice and Delinquency Prevention
and/or applied directly to CSPV (Blueprints).
Applications provided program implementation details,
including the subject in which LST was to be taught, class size,
names of instructors, timelines, and other site-specific
information. Each site was asked to identify a local
coordinator to monitor program activities, help overcome
challenges, and communicate with CSPV (Blueprints) and
NHPA. Written letters of commitment from school
principals and superintendents also were required. (See
Additional File 1 for more information describing the site
Feasibility visits were then conducted by CSPV
(Blueprints) staff and certified LST trainers from NHPA to verify
application information, describe the core elements of the
program, explain the research requirements of the project
(with a strong emphasis on the need to implement the
program with fidelity), assess commitment to implement
LST with fidelity, and address local concerns. Selection
decisions were based on site readiness and ability to
replicate the program. Given the small number of applications
received, most sites were accepted into the study, but
those that were clearly unprepared (e.g., demonstrating
little support from administrators and/or teachers) or
were unable to fulfil the project's requirements (e.g.,
unable to allow observations of lessons) were not selected.
Teacher training workshops
Each site received a two-day training workshop in the first
year of implementation, and a one- or two-day workshop
in the second and third years to familiarize staff with the
program rationale and the key components of each
lesson. Training was required for all LST instructors and local
coordinators, and was encouraged for school
administrators and other support staff. (See Additional File 1 for
more details regarding LST training workshops provided
in the Blueprints Initiative.)
Technical assistance (TA)
Technical assistance with program issues was provided by
LST trainers from NHPA. As part of the process evaluation,
CSPV (Blueprints) staff visited sites once per year to
conduct informal interviews with LST program coordinators,
principals, classroom observers, and some teachers.
Discussions focused on the progress of implementation,
including support for the curriculum, problems
encountered, and solutions achieved. Staff also observed LST
classes, usually in conjunction with local observers, to
assess the reliability of their information. CSPV
(Blueprints) and NHPA staff provided telephone-based
technical assistance (TA) to local coordinators as needed during
the school year, focusing on implementation progress and
achieving solutions to implementation challenges. At the
end of each school year, CSPV (Blueprints) provided each
site with a written report describing the overall project
results, as well as site-specific information regarding the
extent of implementation fidelity achieved, obstacles
faced and overcome, and recommendations for
improvement. Schools could request phone, email, or on-site TA
from NHPA trainers throughout the project. (See
Additional File 1 for more detail regarding the provision of
The independent variables included in the analyses were
largely derived from prior research that assessed
implementation fidelity of eight Blueprints programs (not
including LST), replicated in 42 sites . Variables in this
study include ratings of the program training workshops,
characteristics of the LST program, school-level
characteristics, administrative support, staff buy-in, parent
awareness of the program, quality of the local coordinator, time
spent teaching classes, and student behavior. Most
independent variables were based on self-reports from LST
instructors or site coordinators, though one measure each
was obtained from LST trainers, CSPV staff, and local
classroom observers. Variables were coded so that higher
scores reflected more successful implementation fidelity.
Descriptive statistics for all variables are given in Table 1,
and individual measures are described in more detail
Teacher reports were based on written mail surveys
conducted at the end of each program year, which were
collected and sent to CSPV by site coordinators. All surveys
were conducted anonymously, and response rates were
fairly high: over the three years, about 70% of teachers
completed year-end surveys. Multiple teachers
implemented LST during the three-year study, though some
teachers participated each year and may have responded
more than once. Teacher reports were averaged to create
site-level scores for each implementation measure. Both
Mean Score r Implem. Score r Teach All r Interactive r Student Particip.
1 All variables are coded so that higher scores represent better outcomes.
* Pearson Correlation is significant at the .05 level (2-tailed).
** Pearson Correlation is significant at the .01 level (2-tailed)
independent and dependent variables were assessed at the
site level, rather than for individual teachers. This
procedure was used because the study aim was to examine the
ability of schools as a whole to replicate the LST program
with fidelity, and certain site-level characteristics were
expected to influence implementation procedures. Scores
also were collapsed across program years because each
year of implementation covered similar themes and
topics. Additionally, feedback on implementation was
provided in annual reports to all sites, and all information in
these reports was collapsed at the site level to avoid
embarrassment to individual teachers in small schools, as
well as any repercussions that might occur at the
administrative level due to inadequate or incomplete
implementation by a teacher.
Written mail surveys were completed by local site
coordinators at the end of the three-year project. Coordinators
reported on 42 items related to program implementation,
characteristics of the local school district and program
implementers, training and technical assistance, and
support for the program. Each item was rated on a five-point
scale identifying the extent to which it was a "significant
barrier" (rating of "one") or "significant asset" (rating of
"five") to implementation as a whole, throughout the
project. In all, 104 of the 105 surveys were completed by
The overall quality of the training workshop was
measured from reports by the site coordinators at the end of the
three-year period, teacher reports conducted at the end of
each training workshop, and trainer surveys also collected
at the end of the workshop. Coordinators rated the overall
quality of training workshops from one ("significant
barrier to implementation") to five ("significant asset to
implementation"). Teachers and trainers rated the
workshop on a five-point scale (from "poor" to "excellent").
The three reports were averaged to form the training
quality measure (Cronbach's alpha of 0.49).
LST program characteristics
Coordinators rated the extent to which four characteristics
related to the LST program (the quality of the materials,
flexibility, time required, and complexity) were a barrier
(score of one) or asset (score of five) to implementation.
These items were combined to form the program
characteristics scale (alpha of 0.70).
The school characteristics scale (alpha of 0.87) was
derived from 13 items rated by coordinators, including
staff participation, administrative support, open
communication between agency staff, fit between program and
agency, cohesion and collaboration, clarity of goals, clear
lines of authority, structural stability, champion, facilities,
financial support, resources for program, and political
climate. Each item was rated on a five-point scale (from
"significant barrier" to "significant asset" to implementation).
A separate measure was derived from teachers who
reported the degree of administrative support for LST,
rated on a five-point scale, from "not at all supportive" to
The overall quality of the LST coordinator was rated by
Blueprints staff using a three-point scale ("poor",
"average", and "excellent").
Classroom observers rated student behavior during
lessons on a five-point scale, from "poor" to "excellent."
Prior studies have identified four primary elements of
implementation fidelity: adherence, dosage, quality of
delivery, and participant responsiveness . In this
project, we created a measure for each of these four
domains of fidelity. Classroom observations of teachers'
delivery of the LST curriculum measured adherence to the
curriculum ("implementation score"). CSPV contracted
with one or two local consultants at each site to assess
implementation fidelity through classroom observations
of lessons. To avoid bias, observers were not school staff.
The only qualifications required were an interest in youth
prevention and having the available time to devote to the
project. The observers attended LST training workshops to
meet instructors and learn about the curriculum. Written
instructions were provided for completing the LST fidelity
checklist, and CSPV representatives conducted telephone
conversations with observers after training to ensure that
they were prepared to begin classroom observations. The
observers then were asked to attend four (26%) of the 15
classroom sessions taught by each LST instructor during
level one, three (30%) level two lessons, and two (40%)
level three sessions. During each observation, the
proportion of objectives and activities taught was identified
using a fidelity checklist designed by the program
developer and used in prior evaluation trials and program
replications of LST [14,23,28,33,56] An implementation
score for each lesson taught was calculated as the
percentage of material taught out of all required material. For
example, a lesson in which five of ten required objectives
were delivered received an implementation score of 50%.
Average implementation scores were then created for each
site, based on all teachers and years of implementation
observed for that site. Implementation scores for two sites
that withdrew prior to year-one implementation could
not be calculated. Observers also were asked to identify
the use of varied instructional techniques, assess student
participation, and note any problems, such as deviations
from the curriculum, student behavior issues, or
inadequate facilities. Observations were not scheduled in
advance with teachers, and observers were instructed to
refrain from participating in the lesson or interacting with
students to preserve the naturalistic classroom setting.
Blueprints staff supervised observers by reviewing
observation procedures in phone calls and written
correspondence prior to implementation, talking to observers during
implementation about their work, and conducting joint
During yearly site visits, Blueprints staff conducted
classroom observations with the local observers to validate the
accuracy of the information. During the three-year
project, 302 joint observations were conducted. Ratings
were compared on each pair of implementation
checklists. The observer and staff correspondence across all
levels and years of implementation was 89.7%, indicating a
high level of reliability of the observer information.
LST dosage ("teach all") was based on a question in the
year-end teacher surveys that asked instructors to check all
lessons that they taught during the year. This question was
then coded as a dichotomous measure. If a teacher had
taught every lesson, s/he received a score of one; if not, a
score of zero was given. An average score was created for
each site, based on all teachers and years of
Quality of delivery ("interactive") was assessed as the
percentage of the class period spent using the three
recommended interactive teaching techniques (classroom
discussion, skill demonstration, and behavioral
rehearsal). This measure was reported by classroom
observers on the fidelity checklists. A summary score was
created for each site, based on all site observations over
the three-year period of implementation.
Participant responsiveness ("student participation") was
measured by teacher year-end survey responses to the
item: "What percent of students participated in LST
activities that you taught?" A summary measure was created for
each site, based upon the responses from all LST
instructors at the site and averaged across the three years of
Results for the research questions are based on teacher
and coordinator surveys, observations of lessons (from
consultants and Blueprints staff) and qualitative
interviews conducted by research staff with key participants.
Results are primarily descriptive in nature. The third
research question, identifying predictors of
implementation fidelity, was analyzed using quantitative data from
written surveys and observations. Multiple linear
regression was used to identify predictors of the four elements
of implementation fidelity. All independent variables
were entered into the model simultaneously, and
significant predictors (p < 0.05) were identified.
Did the LST program reach the intended, universal
population of middle school students?
A prerequisite of site selection was that schools
implement the program with all eligible students. At the
beginning of each school year, schools were required to submit
schedules of implementation that identified the dates and
times during which LST would be offered to the targeted
population (all 6th8th or 7th9th grade students).
Schedule adherence was verified by the local classroom
observers at each site. When problems arose that
prevented teachers from reaching all students, Blueprints staff
were usually notified by the local observer, and efforts
would be made to resolve the problems. Typically, the
lack of instruction was due to a lack of trained teachers
(caused by staff turnover after the initial training). In these
cases, a second training or TA visit was held to train
additional instructors. Sometimes, schools or teachers delayed
in teaching students due to scheduling problems or lack of
enthusiasm. For these cases, Blueprints staff worked with
local coordinators to motivate instructors to begin
teaching the program.
Although 100% exposure was not obtained in every
school, all efforts were made by Blueprints staff to ensure
the program was delivered to the intended population
and that all eligible students received the program. For the
most part, this was accomplished successfully. During the
three years of implementation, the LST curriculum
reached approximately 172,355 students.
To what extent was the LST curriculum implemented with
Our primary measure of implementation fidelity was
teachers' adherence to the LST curriculum, defined as the
proportion of critical objectives and activities taught
during observed lessons. As shown in Table 2, instructors
were observed to closely follow the curriculum. The
average site adherence score of 86% indicates that 86% of the
required material was taught by teachers in participating
schools during the three-year project. High rates of
curriculum adherence were demonstrated for all three levels of
the LST program, with average fidelity scores of 86% for
the level one, 85% for level two, and 88% for level three.
Deviation in adherence across sites was not great, as
overall scores ranged from 64%98%. However, individual
teachers varied in the extent to which they taught the
critical program objectives. Individual teachers were
observed to teach between 0%100% of the required
information (results not shown).
Program dosage whether or not all lessons were taught,
and the average length of lessons was reported by
teachers in year-end surveys. As shown in Table 2, 71% of
teachers reported teaching all required LST lessons (15 in
level one, ten in level two, and five in level three). This
outcome varied by level (year) of implementation, with
77% of level one LST instructors completing all level one
lessons, compared to 75% of level two teachers, and 60%
of level three teachers. Although we cannot state with any
certainty why the drop occurred in year three, we did
receive reports from many teachers that the booster
lessons were repetitive with information in prior years.
Teachers reported an average class length of 48 minutes
1Reported by classroom observers
2Reported by classroom instructors
(with a range of 33 to 68 minutes, as shown in Table 1),
which closely matched the dosage requirement that LST
lessons be a minimum of 50 minutes.
A key aspect of the LST curriculum is variation in
instructors' teaching techniques that includes didactic
instruction, discussion, demonstration, and behavioral rehearsal
as appropriate during lessons. According to observer
reports, teachers spent, on average, 37% of class periods
facilitating student discussion, 32% using didactic
instruction, 20% conducting behavioral rehearsals, and 12%
demonstrating skills. Teachers reported high participant
responsiveness to the program. On average, across the
sites, 89% of the students participated in lessons.
What factors were associated with implementation
As shown in Table 1, teachers and coordinators reported
high ratings of the independent variables hypothesized to
relate to the quality of implementation fidelity in this
project. As rated by teachers, coordinators, and LST
trainers, the quality of the training workshops was "good"
(4.31 on a five-point scale). Similarly high ratings were
given for the LST program overall (rated by site
coordinators as 3.42), support for the program from both school
administrators (4.22) and teachers (3.68), and healthy
school environments (3.89).
These variables demonstrated modest bivariate
correlations with the dependent variables that measured
implementation fidelity of the LST curriculum (see Table 1).
Higher implementation scores were associated with
higher ratings on all independent variables except the
quality of the training workshop (r = -0.14). Of these
measures, parental awareness of the program and student
behavior were significantly related to the implementation
score. Characteristics of the LST program were
significantly related to dosage ("teach all") because teachers
were more likely to teach all the lessons if the curriculum
was of high quality, flexible, and easy to use (as rated by
coordinators). The use of interactive teaching techniques
was significantly associated with better student behavior,
but less teacher support of the program. Student
participation was statistically correlated with greater parental
awareness of the LST program and strong administrative
Tables 3, 4 and 5 present the results of the multivariate
analyses used to assess the relationship between the
independent variables and the four measures of fidelity:
adherence, dosage, quality of implementation delivery and
participant responsiveness. As shown in Table 3, two of
the nine independent variables were significantly (p <
0.05) related to the implementation adherence score,
with the quality of the LST program and better student
behavior related to a greater proportion of material taught
by teachers. Two variables were marginally related (p <
0.10) to adherence. Longer LST classes and the quality of
the LST coordinator were associated with greater fidelity
to the curriculum. Several variables were not significantly
related to the adherence score, including training quality,
characteristics of the school environment, administrator
support, teacher support, and parental awareness of the
Table 4 shows the relationship between independent
variables and implementation dosage (i.e., teaching all
required lessons). The quality of the LST program was the
only variable significantly related to dosage, and is an
indication that coordinators' positive views of the
program were associated with teaching all required lessons.
The results in Table 5 demonstrate a significant
relationship between better behaved students and teachers'
greater use of interactive methods. Since data are
crosssectional, however, it cannot be determined whether
using interactive teaching techniques led to better student
behavior, or whether better student behavior was
conducive to greater use of these techniques. Less intuitively,
teachers who were more supportive of the LST program
were less likely to use interactive teaching techniques.
None of the independent variables were statistically
related to the last measure of implementation fidelity,
student participation. Results are not presented.
What obstacles and barriers were encountered during
implementation, and how were they addressed?
The quantitative ratings cannot capture the depth or range
of experiences faced by schools and instructors when
implementing the curriculum. The next section identifies
the general and specific challenges that were faced during
the project, describes how school personnel responded to
them, and assesses the extent to which challenges were
overcome during the three years of LST implementation.
Information is largely based on the qualitative data
obtained during site visits by Blueprints and NHPA
Implementation failures occurred throughout the three
years of the project, when sites or schools were unable to
successfully implement the LST curriculum or fulfill the
research requirements. Full implementation failure
occurred in six sites, representing seven schools. One site
withdrew prior to year-one training because of a major
reorganization in the school district that temporarily
closed the charter school where LST was to be
implemented. Another site began implementation but
withdrew during year one, and the other four sites withdrew
from the project during year two, usually before receiving
an LST booster training.
Of the six site failures, two occurred at sites in which
outside prevention agencies had applied for the grant and
were delivering the program. Funding problems within
these agencies and miscommunication between the
school and the agency were related to failure, as was lack
of strong principal support. The other four failures were
related to either administrative changes and lack of buy-in
from new principals or problems with integrating LST into
the school schedule.
In addition, 22 schools from 17 other sites withdrew from
the project over the three years of implementation (nine
of these schools withdrew prior to year one training and
implementation). These cases often were related to low or
no teacher attendance at required LST training workshops.
As explained below, this challenge was faced to some
degree by many schools; however these failures
represented an extreme problem, or multiple problems, that
could not be resolved. Every effort was made to provide
support to schools and sites that considered withdrawing
from the project, but TA did not always help these sites.
For example, make-up staff training workshops were held,
but in sites facing organizational upheavals or
communication failures, second trainings often were no more
successful in ensuring teacher attendance than the initial
Teacher training workshops
Although all LST instructors were required to attend
training workshops, absenteeism often occurred. When
absences signaled a clear lack of commitment from the
site (e.g., if all teachers from a school were missing),
schools were asked to withdraw from the project. If
absenteeism reflected a lack of communication between school
personnel, such as administrators failing to provide
substitute teachers, or scheduling other required workshops
on the same day, sites were offered make-up trainings.
Staff turnover after training was common, and typically
delayed implementation until another training
opportunity could be arranged. In a few cases, sites did not
identify the teacher turnover, and either allowed untrained
instructors to deliver the lessons, or chose not to deliver
the program to the teacher(s)' classes. Schools could avoid
implementation delays by sending additional staff
(particularly guidance counselors) to trainings who could
teach lessons if needed, but doing so was often difficult
for schools to arrange.
Integrating the LST curriculum into the school schedule
Many schools struggled to integrate the three-year LST
curriculum in their existing schedules, particularly as the
program was to be received by all students, ideally in classes
lasting at least 45 minutes with fewer than 35 students.
The most common barrier to integration was finding time
outside of "core" academic subjects, and this challenge
increased during the project, just as academic pressures to
fulfil standardized test requirements also increased.
Placing LST in non-academic subjects was not always the best
solution. When students realized their elective courses
would be used to teach a curriculum, they could be critical
of the program and disruptive during lessons, which was
significantly associated with lower teacher adherence to
the curriculum. Some schools scheduled LST into short
homeroom periods or other free periods, which resulted
in less time to teach required material (also negatively
associated with implementation fidelity) and often to
student behavior problems.
Implementation during physical education classes was a
common, but not effective solution to scheduling
difficulties. Classes were sometimes combined during physical
education (PE) and resulted in class sizes of nearly 100
students in one site, which could exacerbate behavior
problems. Moreover, participation in discussions and role
plays suffered in large classes, as not all students could
participate, and some were reluctant to share personal
experiences in front of large groups of their peers,
particularly those they did not already know. Finally, some PE
classes were held in the gym, cafeteria, or even outside,
and were a distraction for both students and teachers.
Over the three years of the project, many sites integrated
the program into their curriculum, sometimes by trying
various arrangements until finding a niche. Particularly
successful strategies included identifying a subject, such as
health, in which similar information was being taught,
and replacing that material with LST lessons, or matching
the LST curriculum with state or district teaching
requirements so that all school personnel felt the time was well
spent and not viewed as additional class work.
Although teachers and observers generally reported good
student participation in lessons, student behavior
problems nonetheless occurred with frequency. These issues
were especially apparent in large classes and during
discussions and behavioral rehearsals. In turn, misbehavior
led some teachers to avoid interactive exercises or to
spend too much time managing student behavior
problems, which resulted in less time to cover the required
Classroom behavior problems were difficult to overcome,
particularly for instructors from outside the school system
who were unfamiliar with students. In these cases,
classroom teachers were asked to help manage student
behavior. Likewise, if possible in large, combined classes,
teachers divided the workload so that one teacher taught
while the other monitored behavior. In extreme cases,
sites (or research staff) requested TA from LST trainers,
who modeled teaching techniques designed to prevent
student misbehavior, and/or reviewed strategies for
facilitating discussions and behavioral rehearsals while still
covering required material.
Lack of support for the program
While the measures of support from coordinators, school
administrators, and teachers were not strongly related to
program fidelity in multivariate analyses, support from
key participants could influence program monitoring,
training workshops, and other implementation
procedures. Enthusiastic local coordinators were able to
provide the onsite monitoring and proactive problem-solving
that external research staff could not. Conversely,
coordinators who lacked interest in the program typically failed
to monitor program activities and intervene when needed,
such as identifying teacher turnover and arranging new
training workshops, or ensuring that LST schedules were
being followed. Other coordinators lacked authority to
effectively manage the program. When classroom teachers
or guidance staff acted as coordinators, ensuring full
teacher attendance at training workshops or scheduling
LST classes could be difficult, as this required approval
from school administrators. Coordinators who were too
far removed from the classroom (e.g., those in school
district offices) were often not perceived as credible by
teachers, and thus had difficulty communicating with
instructors or offering assistance.
School principals and district administrators needed to
promote the program, when adopting and integrating it in
the school schedule as well as during implementation, to
bolster enthusiasm from other staff and ensure that
lessons were taught. Active administrators introduced the
program to teachers and elicited their support, attended
teacher training workshops, observed lessons, kept
informed of implementation progress, and even taught
classes in some cases. In contrast, other principals did not
make the curriculum a priority, perhaps due to competing
demands and increased pressure to raise students'
academic performance. In more extreme cases, a lack of
principal support could lead to site failures. In two failed sites,
outside prevention agencies had coordinated the project
and provided LST instructors, but had not engendered full
support from administrators. As a result, when they were
unable to continue teaching the program, principals
refused to take on the burden. One site could not find a
suitable subject in which to teach the curriculum, and the
principal was unwilling to make room in the school
schedule. Another failed site involved principal turnover,
with the new principal overwhelmed with new duties of
the job and unwilling to spend time trying to integrate the
program into the school curriculum. Research staff
solicited administrator enthusiasm and support by requiring
principals to sign letters of commitment as part of the
application process, as well as through personal visits to
discuss the goals of the project, progress of
implementation, and administrator involvement in the initiative.
Teacher support for the program varied by site and over
time. While the majority of instructors had very positive
views of the program, others resented the mandate to
teach LST, particularly when their input was not solicited,
and when they were overburdened with other
responsibilities. Some teachers did not support LST because they felt
similar material was already being taught in the school,
they disliked the content or theory of the program, or they
felt other drug prevention curricula were better. Other
reasons for a lack of teacher support included concerns about
being observed, or feeling that project guidelines
regarding fidelity were too rigid and did not allow for teacher
creativity and flexibility.
Teacher dissatisfaction sometimes resulted in instructors
deviating from the curriculum by supplementing lessons
(i.e., adding videos, "scare tactics," or other activities) or
deleting information, activities, or entire lessons. Some
teachers were observed telling students that they had to
"get through" LST lessons before they could begin other
work. Not surprisingly, students in these classrooms
tended to be uninvolved and disruptive. When instructors
from outside the school taught lessons, classroom
teachers often appeared uninterested in the material (some
were even observed reading newspapers and paying bills),
and students typically responded with boredom and
restlessness. Instructors' lack of buy-in also contributed to site
failures. If both instructors and administrators were
reluctant to champion the program, the likelihood of
overcoming challenges was diminished.
During implementation, CSPV staff met with as many
instructors as possible to listen to their concerns, thank
them for their support, and recommend that those with
problems seek technical assistance from trainers. In site
visits and year-end reports, coordinators and school
administrators were encouraged to foster teacher support
by scheduling regular meetings with staff, and providing
guidance counselors or others to co-teach lessons if
teachers requested such assistance. Even if this advice was not
followed, teachers who did not enthusiastically endorse
the program were sometimes observed to effectively
deliver lessons, which may help to explain the lack of
significance between teacher support and implementation
Widespread replication of effective prevention programs
is unlikely to affect the incidence of adolescent
delinquency, violent crime, and substance use until the quality
of implementation of these programs by
communitybased organizations can be assured. This paper presents
the results of a process evaluation focused on identifying
the extent to which schools participating in the Blueprints
for Violence Prevention Initiative were able to successfully
implement the LST drug prevention program. In addition,
the project identified factors that promoted
implementation quality, challenges that were faced during
replications, and the degree to which problems were overcome.
The process evaluation demonstrated very high rates of
implementation fidelity among the sites and schools
participating in the project. According to observer reports,
sites delivered, on average, 86% of the program objectives
and activities required in the three-year curriculum.
Teachers were observed using all four recommended
teaching practices (didactic instruction, discussion,
demonstration, and behavioral rehearsal) and student
participation in lessons was good. Teachers and site
coordinators also reported strong implementation
outcomes and satisfaction with the program. For example,
end-of-year surveys demonstrated that 71% of the
teachers delivered all the required LST lessons over the
threeyear period, class length was in accordance to dosage
requirements, and satisfaction with the curriculum was
better than average. Program coordinators rated the LST
program favorably with regard to the quality of the
materials, flexibility, time required, and complexity. Another
measure of the success of the program was shown by the
high rate of student participation. On average, 89% of
students participated in lessons.
Factors related to each of the four components of
implementation fidelity (i.e., adherence, dosage, quality of
program delivery, and student participation) were also
assessed in four multiple regression models. LST program
characteristics and student behavior were associated with
outcomes in two of the four models. Sites whose
coordinators had rated the LST program favorably with regard to
quality, flexibility, complexity, and time required had
higher levels of teacher adherence and dosage. Program
developers are increasingly producing detailed manuals
that specify the nature of the required program
components . Attractive packaging of a curriculum and ease
of use are important considerations in school-based
programs. Teachers often lack the time to develop lessons and
activities around violence and drug prevention. Programs
that are well-developed and contain specific instructions
and activities for implementation can be extremely
beneficial to teachers who are already overburdened. In an
earlier Blueprints project in which eight other Blueprints
programs were replicated, ideal program characteristics
were found to be related to higher dosage and
sustainability of the program .
Better student behavior was related to higher teacher
adherence and use of interactive teaching techniques.
Teachers who spend excessive amounts of time
reprimanding and striving to maintain control of a class have
less time to teach the lessons and engage students in
meaningful discussion and behavioral rehearsal. Teachers
who are not adept at managing their classes may avoid the
use of interactive techniques for fear of losing control of
the class. Our own observations in classrooms showed
that teachers with poor classroom management skills
often lost control of the class when using interactive
techniques. This suggests that schools should consider teacher
training in classroom management skills prior to
adopting programs that use interactive techniques, such as LST.
Two other variables were marginally related to teacher
adherence: the quality of the local coordinator and a
greater amount of time spent teaching each lesson. In the
absence of a strong and proactive coordinator, programs
can drift. A good coordinator can provide direction,
leadership, and motivation to keep implementation on track.
Good coordinators maintained contact with teachers,
identified potential problems, and worked to resolve
them before they became major obstacles. Allowing
adequate time to teach each lesson was also important.
Qualitative interviews with program staff provided additional
support for this finding. Instructors frequently reported to
research staff that it was difficult to cover all the required
information, even in a 50-minute class period. Time
constraints were exacerbated when teachers had to use
instruction time to manage student misbehavior.
It is difficult to interpret the finding that greater teacher
support for the program was related to less frequent use of
interactive teaching techniques. We suspect that many of
the teachers lacked the skills and experience to use the
interactive methods. They may have been very motivated
and supportive of the program, but unable to adjust to the
more frequent use of these teaching techniques. Some
motivated teachers may have limited their use of the
interactive techniques in classrooms that contained students
who were difficult to manage. In fact, good student
behavior and the use of interactive techniques were positively
correlated. LST training workshops exposed instructors to
these teaching techniques; however, instruction in
effective classroom management techniques was not included,
and more in-depth training in the efficient use of these
techniques may be necessary.
Though research on factors related to implementation
fidelity is growing, this is a relatively new area of study
and few other studies to date have relied on quantitative
analysis to identify these factors. In the Blueprints
Initiative process evaluation of 42 sites replicating eight model
programs, multivariate analyses showed several factors
related to implementation fidelity, including quality of
technical assistance, ideal program characteristics,
consistent staffing, and community support . The National
Study of Delinquency Prevention in Schools
demonstrated significant correlations between a number of
school- and teacher-level factors and program quality,
including the quality of the program coordinator,
integration into the school schedule, organizational support, and
standardization of program materials .
Unlike the National Study of Delinquency Prevention in
Schools, the Blueprints Initiative provided schools with
program materials, teacher training, and technical
assistance to replicate the LST program. In addition, sites were
screened in advance to determine their readiness and
support to implement the program with fidelity. Throughout
the project, Blueprints staff provided program monitoring
to ensure that curriculum activities were taking place and
to encourage fidelity. One-third to one-fourth of all
lessons were observed. Given this level of support and
encouragement to implement with fidelity,
implementation of the curriculum did not occur under typical, "real
world" conditions. Thus, schools participating in this
project may not be representative of all schools that might
choose to implement LST, and the support provided may
have resulted in higher implementation levels than might
otherwise be observed. In fact, the results demonstrated
implementation fidelity rates even higher than those
found in LST research trials and some replication efforts.
It may be that the most important predictor of
implementation quality was the technical assistance provided, and
that this support overshadowed other factors that might
be more important in community-based replications that
do not receive this level of technical assistance.
Given the nature of this project, the results of the
multivariate analyses should be viewed with some caution.
Most of the independent variables were assessed using
self-reported information from LST instructors and local
coordinators. Not all teachers completed surveys, and it is
possible that teachers who were less supportive of the
program did not participate in the assessment. In addition,
data were cross-sectional, and causal inferences regarding
predictors and outcomes could not be made. These
limitations emphasize the need for additional studies
assessing predictors of implementation quality in
communitybased replications of prevention programs. More research
is needed to identify the degree to which communities can
replicate programs successfully, and more quantitative
analyses of factors that influence the successful adoption
of new programs are needed. In particular, studies
utilizing multiple respondents, longitudinal designs, and
random assignment are needed.
Despite the levels of program monitoring and support
provided in the Blueprints Initiative, it is telling that
schools nonetheless faced many challenges during
implementation. Interviews with program staff indicated
barriers related to finding room in the school schedule for the
program, with schools trying to avoid taking time away
from academic subjects but also risking student
resentment if electives or free time was used to teach LST. Most
schools struggled to some extent with gaining full support
from key participants, including site coordinators,
instructors, principals and other school administrators. Finally,
student misbehavior and classroom management
difficulties were reported by many teachers, particularly when
trying to implement the interactive components in the
In most cases, schools were able to overcome barriers, at
least over the course of the three-year project. Schools also
varied in their willingness to identify challenges to
research staff. Most schools seemed reluctant to ask for
TA, even though they were strongly encouraged at the start
of the project and in annual reports to utilize the free
technical assistance available. In many cases, Blueprints staff
did not learn about problems until site visits were made,
and requests for visits by LST trainers were rare. We
quickly learned that "no news was good news" did not
apply to the schools participating in this project and that
proactive TA (versus waiting for schools to contact TA
providers) was needed to identify and solve implementation
During the past decade, we have learned much about the
importance of implementation fidelity in achieving
effective outcomes, and about what is required to attain a
highquality implementation. The primary lesson learned in
this project was that schools can effectively replicate
evidence-based drug prevention curricula, including
teaching the majority of required lessons, content, and
activities in a manner that engages students. Doing so
involves much planning and problem-solving, and
schools must be ready to encounter challenges. Even
when problems are encountered and solved, they may
reappear later in implementation and have to be resolved
again. The provision of technical assistance and
implementation monitoring is critical for identifying and
overcoming barriers to implementation. Implementation
fidelity was especially high in this project due to the level
of TA support provided by NHPA and the implementation
monitoring by Blueprints staff. Under natural conditions,
schools may not achieve the same level of fidelity as found
in this project, but even without this high level of support
schools can still improve implementation fidelity (and
hence outcomes). Purchasing a curriculum and asking
teachers to implement, in the absence of training,
support, and monitoring, will seldom be sufficient. School
administrators must be proactive in supporting teachers'
efforts to replicate programs. This includes choosing
programs carefully to ensure fit, ensuring that teachers are
trained in the program model and in classroom
management skills, building an internal mechanism of ongoing
support (e.g., assigning a trained program coordinator),
and instituting at least some minimal form of internal
monitoring that provides corrective feedback to teachers
and administrators regarding implementation.
The replication project was directed by SFM, and AF and
SA were project managers at different time intervals
throughout the project, overseeing field staff and data
collection. SFM conceived of the study, and SFM and AF
participated in the study design, statistical analyses, and
writing. AF had a major role in preparing the first draft. SA
prepared the file for analysis. All authors read and
approved the final version.
Support for this project was provided by the Office of Juvenile Justice and
Delinquency Prevention through grants #98-DR-FX-001 and
#2000-DRFX-K001. The authors also wish to acknowledge the hard work and
dedication demonstrated by all the members of the research team involved in
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