This randomized prospective trial aimed to assess the feasibility and efficacy of a team-based worksite health and safety intervention for law enforcement personnel. Four-hundred and eight subjects were enrolled and half were randomized to meet for weekly, peer-led sessions delivered from a scripted team-based health and safety curriculum. Curriculum addressed: exercise, nutrition, stress, sleep, body weight, injury, and other unhealthy lifestyle behaviors such as smoking and heavy alcohol use. Health and safety questionnaires administered before and after the intervention found significant improvements for increased fruit and vegetable consumption, overall healthy eating, increased sleep quantity and sleep quality, and reduced personal stress. In the U.S., close to 800,000 individuals work in law enforcement . ChargedAdditionally, law enforcement personnel are a high-risk group for musculo-skeletal injuries, fatigue/stress-related disorders, sleep disorders, metabolic syndrome, and cardiovascular disease –11. OverLaw enforcement work is characterized by tight knit groups of colleagues who rely on each other for safety. This work structure and organization culture is suited for a team-based health promotion program comprised of colleagues working the same shift or fulfilling similar work roles. We have demonstrated success impacting health attitudes and behaviors through other team-based health promotion programs for athletic teams and firefighters –19.The safety and health improvement: enhancing law enforcement departments (SHIELD) study is sponsored by the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health to investigate strategies to promote health and safety of law enforcement personnel. SHIELD addresses modifiable factors that synergize to adversely impact law enforcement personnel’s health, safety, and work performance: high stress, sleep deprivation, lack of physical abilities, and unhealthy lifestyles –24. The The objective of the SHIELD study was to test the feasibility and potential efficacy of this team-based intervention approach. We report the trials’ 6-month findings. We hypothesized that law enforcement workers’ health and occupational safety would be improved with a peer-led, team-based health promotion and protection program.One police department and two sheriff’s offices from Oregon and southwest Washington were identified and recruited for participation in this study. The two sheriff’s offices were recruited due to similar size, staffing patterns, and scheduling. The police department was recruited due to its natural division of staff into two precincts.Partnering law enforcement organizations were one police department, which at the time of study recruitment employed approximately 200 sworn and 35 civilian staff; a sheriff’s office employing approximately 246 sworn officers and 106 civilian staff; and a sheriff’s office with 244 sworn officers and 97 civilian staff. A total of 408 individuals from across the participating organizations consented to participate in the 2-year study. The Institutional Review Board of the Oregon Health & Science University first approved the study in April of 2010.Within each of these agencies, study participants were organized into teams. Teams consisted of three to seven persons who work together at the same or similar jobs. Most teams were naturally occurring , and some teams were assigned based on similar job description and work location . Teams were then organized into blocks based on shift, schedule, and physical work location. Each block consisted of one to six teams. The blocks were organized into matched pairs: patrol blocks were matched with patrol blocks, jail staff blocks matched with jail staff blocks, training unit blocks matched with training unit blocks, and remaining blocks matched in a similar manner. Blocks were used for matching in the randomization only, and had no bearing on program delivery. The formation of blocks reduced the risk of contamination between teams.This matching scheme organized the 86 teams into 42 blocks, or 21 matched pairs of blocks. After the blocks were randomized, 204 participants from 45 teams in 21 blocks were in the treatment condition and 204 participants from 41 teams in 21 blocks were in the control condition.For the three departments, of the 928 eligible employees, 408 recruited individuals met inclusion criteria, and the allocation, follow-up, and assessment numbers are presented in Figure http://ripl.faculty.asu.edu/All study participants received comprehensive medical screening at baseline (results not presented here). As part of the intervention assessment, study participants completed a written survey prior to randomization and approximately 6 months after initial testing. The survey instrument included information about demographics, position, years of service, and work schedule. Items were assessed using constructs with established reliability from our previous studies , supplemEach team received a team box containing the materials needed for the program. Teams consisted of individuals who worked in the same location or type of work on the same shift schedule. One participant from each intervention team was self-selected to serve as team leader. Team leaders received a 20-min orientation to the program and a scripted team leader manual to guide each session. Other team members used corresponding workbooks. The curriculum included 12 30-min, scripted, peer-led, team-based sessions. Sessions were scheduled weekly during work hours. Each session comprised of three or four brief interactive activities about healthy eating, exercise, body weight, stress, sleep, and other lifestyle factors. Language throughout the scripted sessions emphasized the team social support aspect of the program. The peer-led, team format encouraged accountability as well as fostering support at the worksite. Participants were encouraged to check in with one another about the weekly goals and scripted discussion prompts elicited the sharing of suggestions and tips.Research staff observed a random selection of approximately one-third of the sessions, taking notes on participant attendance, engagement, and fidelity using the scripted lesson plans as behavioral checklists.Individuals assigned to teams that were randomized to the control condition participated in the same baseline health assessment and completed the same questionnaires as intervention individuals. Results of the baseline medical screening were communicated to all subjects with appropriate medical advice and follow-up for abnormal test results with their physician. No other health promotion programs or educational materials were provided to control participants.http://ripl.faculty.asu.edu/The statistical analysis incorporated the nesting of individual subjects within the 86 teams. The intraclass correlations for teams at baseline ranged from 0.000 for the Karolinska Sleepiness Scale to 0.052 for total fruit and vegetable consumption. Missing data at the 6-month follow-up were treated as missing at random by including baseline measures in the statistical analysis. This multilevel regression model was estimated using the SAS mixed program using a model for two repeated measures from each subject, clustering of groups of subjects in teams and observations missing at random. More information on the analysis is available as a separate addendum, to be located online via p-values are presented in Table Intervention significance tests were assessed in the multilevel analyses in a repeated measures model where the interaction of condition and time provided the test of the intervention. This group-by-time interaction indicates whether the treatment and control groups changed differently over time for each construct, and thus represents the program effect. Statistical significance with Results from this final model are based on repeated measures from participants, participants in teams, and the use of all data including data from participants only measured at baseline. Additional analyses based solely on individuals or solely on team means generally led to the same research conclusions.Fifty-six of the 408 participants did not complete follow-up at 6-month testing. Of the 56 participants who did not complete post testing, 26 were randomized to the treatment group and 30 were randomized to the control group. For the 37.6% of the sessions observed, the average session length was 31.4 ± 11 min (mean ± SD), and 97% of the scripted content was delivered. During sessions that were observed, the average attendance at the team sessions was 87%. The curriculum was delivered with high fidelity and no other health promotion programs were initiated during the study period.Selected demographics for participants are shown in Table p = 0.0355).Participants in the control group were younger than participants in the treatment group when tested at the individual level but not when accounted for clustering in teams. Given the random assignment of teams to conditions, the statistical test for baseline equivalence in the multilevel model is a more accurate test of baseline equivalence. As shown in Table Program effects for each construct were estimated using a multilevel model, including all individuals nested within one of the 86 participating teams. Table p < 0.0001), vegetable consumption (p = 0.004), combined fruit and vegetable consumption (p < 0.0001), sleep quality (p = 0.0001) and quantity (p = 0.004), stress (p = 0.03), and healthy eating (p = 0.009). A marginally significant program effect was found for the SF-36 measures of general health (p = 0.08), alcohol use (p = 0.10), tobacco use (p = 0.07), and depression (p = 0.09). Notably, other major construct outcome variable effects were in the correct direction, though non-significant, including physical activity, fatigue, and dietary fat consumption. No beneficial effects on burnout or musculo-skeletal pain were obtained.Significant program effects were observed for many program outcomes. Program effects were observed for fruit consumption  experience an increased prevalence of cardiovascular disease due in part to elevated diabetes, hypertension, and hypercholesterolemia. However, other characteristics of law enforcement work likely play a role in these elevated health risks including increased stress and sleep disorders. Recent published results found 40% of surveyed police officers had symptoms consistent with a sleep disorder . Sleep dSimilar to the high prevalence of sleep disorders among LEO’s, there is a high prevalence of stress and stress-related issues among LEO’s. Due to the nature of the job, the law enforcement profession is recognized as particularly stressful with high rates of stress-related mental health issues and suicide , 11, 20.Similar to our firefighter wellness program , signifiSince the intervention was not limited to one site, there was a risk of contamination from intervention subjects communicating program content to control subjects. Randomization by blocks based on physical work location and shift attempted to reduce this spill over. Any communication of program content across teams who did and did not receive the intervention program would have reduced the observed program effect. Further, the randomization within sites precluded adding a work environment component, such as posters or stair reminders, which are frequently a component of worksite safety and wellness programs. This limitation also makes the program effects more striking. Our findings should be generalized with caution outside of this study. Participation in the study was voluntary and may have resulted in the recruitment of individuals who were more motivated to change than the average law enforcement personnel. However the experimental design and relatively high participation enhance the validity of our findings.Law enforcement personnel are a high-risk group for occupational injuries and illnesses, resulting in a life expectancy less than the average American –11. Few The PHLAME program is listed on the Cancer Control P.L.A.N.E.T. website of evidence-based programs, and the PHLAME TEAM program is distributed through the Center for Health Promotion Research at Oregon Health & Science University (OHSU). OHSU and Drs. Kuehl, Elliot, and Goldberg have a financial interest from the commercial sale of technologies used in this research. This potential conflict of interest has been reviewed and managed by the OHSU Conflict of Interest in Research Committee. The remaining authors declare no conflicts of interest.http://www.frontiersin.org/journal/10.3389/fpubh.2014.00038/abstractThe Supplementary Material for this article can be found online at Click here for additional data file.Click here for additional data file.


Despite great need, the number of HIV prevention implementation studies remains limited. The challenge for researchers, in this time of limited HIV services agency resources, is to conceptualize and test how to disseminate efficacious, practical, and sustainable prevention programs more rapidly, and to understand how to do so in the absence of additional agency resources. We tested whether training and technical assistance (TA) in a couple-based HIV prevention program using a Web-based modality would yield greater program adoption of the program compared to training and TA in the same program in a manual-based modality among facilitators who delivered the interventions at 80 agencies in New York State.This study used a cluster randomized controlled design. Participants were HIV services agencies (N = 80) and up to 6 staff members at each agency (N = 253). Agencies were recruited, matched on key variables, and randomly assigned to two conditions. Staff members participated in a four-day, face-to-face training session, followed by TA calls at two and four months, and follow-up assessments at 6, 12, and 18 months post- training and TA. The primary outcomes examined number of couples with whom staff implemented the program, mean number of sessions implemented, whether staff implemented at least one session or whether staff implemented a complete intervention  of the program. Outcomes were measured at both the agency and participant level.Over 18 months following training and TA, at least one participant from 13 (33%) Web-based assigned agencies and 19 (48%) traditional agencies reported program use. Longitudinal multilevel analysis found no differences between groups on any outcomes at the agency or participant level with one exception: Web-based agencies implemented the program with 35% fewer couples compared with staff at manual-based agencies .Greater implementation of a Web-based program may require more resources and staff exposure, especially when paired with a couple-based modality. Manual-based and traditional programs may hold some advantage or ease for implementation, particularly at a time of low economic resources.NCT01863537ClinicalTrials.gov identifier:  Despite the need for implementation science in HIV prevention in the United States, the number of implementation studies remains limited –4. This e.g., balancing attention to the dyad, positive reinforcement for relationship-based behaviors, conflict management) [The challenge for researchers, in this time of limited HIV services agency resources, is to conceptualize and test how to more rapidly disseminate cost-effective, efficacious, practical, and sustainable prevention programs- including behavioral approaches . We cannagement) , scientiagement) . Yet, coagement) ,14. How et al. [Dissemination of evidence-based HIV prevention in the U.S. has taken place largely through the Centers for Disease Control and Prevention’s (CDC) Diffusion of Evidence-Based Interventions (DEBI) program in which agencies receive funding and technical assistance (TA) to deliver ‘packaged’ programs that had been selected as ‘best evidence’ ,17. Thiset al. ,19 and oet al. –24, but et al.  and noneet al. –28 compaet al. ,30. Advaet al.  by offeret al. –35. Scieet al. –41.e.g., delivered sessions). We hypothesized that more agencies (or participants) assigned to implement the Web-based program would report H1, delivering Connect with more couples; H2, delivering more Connect sessions; H3, delivering at least one Connect session; and H4, delivering at least one complete Connect intervention  over the 18 months of follow up, compared to agencies (and staff) assigned to the manual-based approach. In addition we observed post-training use of TA and barriers to implementation.This clinical trial tested the adoption of an HIV prevention intervention model to clinic-based health services in neighborhoods throughout New York State. The goal of the study was to examine whether using a Web-based approach for implementation of a couple-focused HIV prevention program, Connect, yields greater implementation than a traditional, manual-based approach used by facilitators at HIV service agencies. We tested implementation of couple-based intervention modalities  into real world settings. The study investigated how the Internet may be used to support the delivery of a behavioral ‘packaged’ manual-based intervention and ‘packaged’ computer based intervention in agency settings . AlthougThis study was a longitudinal matched pairs cluster randomized trial conducted between 2007 and 2012 ,44. We rHIV services agencies are highly variable in terms of their size, scope of service, and available financial resources. Given this variability, and the relatively small sample size, we decided that a matched pair approach would best guard against imbalance across arms after random assignment. We identified two factors that the research team, in consultation with our community advisory board (CAB), believed might most strongly influence the primary outcomes: number of full and part time paid staff providing HIV prevention services in the prior year; and number of clients receiving multi-session HIV prevention services in the prior year. To create matches for pairing ,44, the http://www.effectiveinterventions.org/en/HighImpactPrevention/Interventions/Connect.aspx) [Participants from agencies randomized to the manual-based intervention were invited to a four-day, face-to-face structured orientation and training on the original, manualized Connect program. In addition, we offered planned, investigative-team-initiated telephone consultations to provide TA at two and four months following the workshop. The traditional Connect program and facilitator training curriculum is one of the CDC DEBIs (see ct.aspx) ,44 and ict.aspx) , with dect.aspx) –50. Connct.aspx) –55.e.g., time spent on which activity, when, and by whom). The translation from manual-based intervention to multimedia version was based on design research methodology [Participants from agencies randomized to the Web-based intervention were invited to a four-day, face-to-face structured orientation and training on the ‘Multimedia Connect’ program . In addition, we offered planned, investigative-team–initiated telephone consultations to provide TA at two and four months following the workshop. The Multimedia Connect program and facilitator training is a translation of the original, which features the same core elements , but rephodology  and scafhodology , and is hodology ,59. The Study implementation was guided by social cognitive and scaffolded learning theories. Social cognitive theory ,60 suggeWe provided scheduled program trainings once or twice per month on a rolling basis for groups of up to five agencies (15 – 20 staff participants) from the same condition . The study was longitudinal with repeated measurement of outcome variables at 6, 12, and 18 months post-training and TA.TA was offered in two ways. As part of each condition, TA was initiated by the research team to each agency at two and four months post-program training. During these hour-long conference calls, participants were asked a series of questions regarding their efforts to implement the program and asked questions regarding any barriers or issues faced. The research team provided support and problem-solving strategies to each issue or question raised. In addition to this TA as part of the process, we also encouraged all participants to call or email at any time throughout the trial if they had any need for support related to implementation of the program. These ‘proactive’ efforts on the part of participants were all recorded as they could also possibly influence the implementation outcomes.As recommended in the literature, we employed a community advisory board (CAB) representing administrators, clinicians, and clients from HIV prevention organizations  to assure.g., delivered sessions), operationalized as follows: the total number of couples with whom staff implemented Connect at each agency; the mean number of Connect sessions implemented by staff at each agency whether staff implemented at least one session of Connect; and whether staff implemented a complete cycle of Connect in the prior six months. Early implementation of this type  offers a window into early use and barriers to use of new programs [Prior to being trained in the program’s implementation, individual staff participants completed informed consent and an online baseline assessment of demographic and organizational characteristics, descriptive variables, outcome variables and barriers to implementation. The primary study outcomes were measures of implementation of the Connect program  ranging from 1.2 to 1.5 to account for the design effect resulting from use of matched pairs during randomization--suggested that 80% power would be achieved with 80 agencies as the unit of analysis.Power analyses--assuming alpha = 0.05, two-tailed testing, minimum ‘small-to-medium’  effect sOrganizational characteristics and stratification factors were analyzed to check for balance and proper application of the random assignment process. Demographic data were analyzed for differences between participants from the two conditions.We relied on an intent-to-treat approach and we used generalized linear models with random effects for repeated measures to estimate differences attributed to assignment  for four primary outcomes at the 6-, 12-, and 18-month follow up: the total number of couples with whom staff implemented Connect at each agency ; the mean number of Connect sessions implemented by staff at each agency (linear regression); whether staff implemented at least one session of Connect (logistic regression); and whether staff implemented a complete cycle of Connect (logistic regression). Originally, the agency was the unit of analysis .To be consistent with the agency level analyses, we used generalized linear models with random effects for repeated measures and agency to account for the clusters of individuals within agencies. Outcomes were operationalized as above, but measured individually: the total number of couples with whom participant implemented Connect at his/her agency; sum of the number of Connect sessions implemented by participant at his/her agency; whether participant implemented at least one session of Connect; and whether participant implemented a complete cycle of Connect. This allowed accommodation for intraclass correlations (ICC) associated with reports from more than one facilitator at a given agency (range 0.16 – 0.54). In addition, the agency level analysis alone would not account for the fact that an agency with more facilitators has higher reliability of estimates compared to those with fewer facilitators.The mean HIV/STI prevention budget for all agencies was $1,068,910; the median was $362,500 . The mean number of full time prevention staff was 18; the median was 9 (range 0 – 216). Table The pool of respondents included 253 agency staff , with an average of three participants per agency (range 1 – 6). Most were female and over 40 years of age. The majority of participants were African American. Participants had an average of seven years of experience in HIV services, and reported high levels of confidence in using both a computer and an Internet browser .Outcomes two, three, and four: There were no differences found between conditions on the average number of sessions completed per facilitator ; the likelihood to implement at least one session ; or the likelihood to complete at least one cycle of Connect .At the participant level, no significant differences were found between groups for any of the four outcomes. The outcome estimates shown in Table Attendance for the investigator-initiated TA calls at two and four months was high , recruitment of couples (46% and 51%), and staff turnover (34.9% and 22%) among manual-based and Web-based conditions respectively. No significant differences between conditions were found on any reported barrier.This study is the first to examine implementation of a couple-based HIV prevention intervention, and the first to test competing modalities for implementation of a behaviorally- based HIV prevention program  among HIV services agencies. Findings did not support our hypotheses, demonstrating instead that whether measured at the level of the agency or the participants, staff trained on the Web-based program did not demonstrate significantly higher implementation compared to those trained on the manual-based approach. Agency level outcomes did demonstrate higher mean number of couples with whom staff at manual-based agencies worked compared to Web-based agencies, however, these findings were not significant at the individual level. Findings also show overall low rates of implementation, but implementation rates that are consistent with the landmark study on which the CDC DEBI approach is based . Our diset al. [As a dissemination trial, commitment from agencies to implement Connect was not an eligibility criterion. Furthermore, we did not offer additional resources or incentives for implementation. Our goal was to observe how agencies managed the process of manual or Web-based implementation with their clients post-training and TA. We did observe implementation: staff at 33% of Web-based and 48% of traditional agencies implemented sessions over 18 months; 17% of participants assigned to Web-based agencies and 26% of staff assigned to traditional agencies implemented sessions over 18 months. A smaller number implemented multiple sessions and cycles and was able to sustain use at low levels. The economic recession that began in 2008 had a devastating effect on HIV services agencies in New York State—some lost as much as 30% of their funding within three to six months. Because most participants reported their agencies were already implementing at least one DEBI, absent additional incentives or funding, more staff may have felt more comfortable implementing the traditional version of Connect, which did not require access to a computer or wireless Internet. Of note is that these low percentages are consistent with and only slightly lower than those reported in Kelly et al. , showingThe expected benefits of a Web-based program notwithstanding, implementation rates may reflect a time of low or dwindling resources or of considerable organizational disruption in services provision due to the recession and related cuts. Examination of data related to changes in organizational budgets over time may further inform interpretation of findings. During the study period four agencies  chose to incorporate Connect into competing grant renewals from New York State or the CDC to continue implementation. These were successful and post 18-month follow-up, these agencies continue implementation. Future trials may consider ways to offer short term resources in support of implementation or increase time spent during training sessions to how best to integrate new programs into existing service delivery or reimbursement mechanisms.Our expectation that facilitators would use a Web-based strategy and facilitate a couple-based intervention at once may have been unrealistic and may also explain the low usage of the Web-based Connect among our agency participants. With few exceptions, the facilitators had never worked with couples. Enthusiasm during program trainings to implement a couple-based program suggested individual level commitment to implement the program. However, many expressed concerns about how they would manage couple-related interventions at their agencies. While Connect activities are simplified for easy implementation and are intended to be delivered by a wide range of facilitators, implementing a couple-based intervention presents a unique set of challenges ,14. Stafi.e., various browsers). It would also be important to create an understanding with adopting agency staff that reporting glitches and bugs is important so that issues can be corrected quickly.Technology management issues including staff comfort and concerns about client data security and confidentiality may also account for our finding that Web-based implementation did not surpass manual-based implementation. Our choice of computer model and browser may have been unfamiliar to staff or different from the standard agency set-up to which they were accustomed. Most participating agencies employed IT staff or consultants that must approve or conduct any changes to agency-related computing; this sometimes delayed downloading and installation of required software and may have created real or imagined barriers to implementation. Further, despite almost six months of beta-testing to ensure there were no major issues with accessibility or utility of the program, ‘bugs’ in the system were reported during TA calls by some staff who tried the program early on. Together, these issues may have impeded a smooth transition to regular use of the program, or worse, led them to decide not to use the program at all. To address such issues in future trials, we recommend creating any Web-based program with support for a range of hardware and software -related concerns regarding access to the information gathered on couples engaged in the Web-based program activities. The program did not save identifiable data, rendering HIPAA concerns unwarranted. Future research should provide follow-up—with support from agency administrative staff—to clarify with staff that any programming adopted at the agency provides adequate protection of client confidentiality.e.g., ‘individual’, ‘group’) for purposes of documentation and billing. Researchers need to work with agencies to identify how best to integrate new couple-based EBIs into new or existing services [Consistent with outcomes, reported barriers to implementation did not differ by condition. The top barriers reported were lack of funding and staff turnover, consistent with existing literature on program adoption ,41,67–70services  and billQualitative data collected in in-depth interviews and site visits to 10% of participating agencies should yield additional insights to further interpret these findings.et al. (2009) [et al. (2012) [Our finding of low TA requests is not a new phenomenon. Veniegas . (2009)  report n. (2012) , in an i. (2012) . Such a e.g. participant experience working with couples) may have strengthened analysis of findings. Finally, the loss of funds to agencies due to the recession during this trial makes it impossible to apply the findings to a more typical economic climate.Findings should be considered in light of several limitations. First, findings can only be interpreted to indicate that we found no evidence for the relationship, not evidence for lack of a relationship. The study was not powered as an equivalence trial, but rather to assess whether the Web-based approach was superior to the manual-based approach. The noted technology challenges are more anecdotal lessons learned to influence future trials, and cannot be interpreted to suggest that they were responsible for lower implementation of the Web-based program. Data were based on self-report only, which in some cases can lead to poor recall, and which can reduce confidence in findings. Operationalizing implementation is challenging; any single measure often inadequate . While wDespite limitations, the study makes critical contributions to HIV prevention implementation science. Findings show the feasibility of training on and implementing both a manual-based and a Web-based version of a couple-based DEBI , and the enthusiasm of HIV services organizations and their staff to participate in implementation trials in the absence of strong economic incentives. In particular, agencies embraced the opportunity to expand service provision to include couple-based and Web-based programming. Couples-based approaches for HIV testing and counseling, as well as for more intensive primary and secondary prevention efforts are increasing. Implementation methods must be identified to best bring them to scale. Increasing interest in both of these areas of HIV prevention efficacy studies suggest the need for more careful study to inform rapid and efficient implementation of efficacious programs.Study findings raise questions regarding the implementation of such programming in the absence of dedicated funding, however, and of barriers. Our interpretation of findings suggest that either a very poor economy, which rapidly reduced resources at participating agencies and led to low overall implementation, and (for one outcome) higher manual-based implementation; or else the combined challenge of using both a web-based curriculum and also implementing couple-based programming for the first time, may have contributed to the lack of hypothesized outcomes. Findings point to several important issues for future implementation research in HIV prevention, with couple-based programs, and/or with Web-based programming. Web-based programming should be built to support a range of browsers and beta-tested thoroughly prior to trial initiation. During trials, participants should receive more frequent proactive TA to ensure movement from the pre-implementation to implementation stages, and more time and assistance to agencies to integrate new programs into their existing program structure and reimbursement mechanisms. This should enhance support from administrators and smooth transitions for line workers managing multiple responsibilities. Support to agencies in identifying external funding for new program implementation should further reduce barriers to implementation. Future dissemination studies should also consider not only a comparison of mediums, but also the features of Web-based programming that can best support facilitators ,73. The In the years since the initiation of this trial, the policy and best practice of HIV prevention and the use of digital technologies have changed dramatically. Interventions are being shortened to one or two sessions in the name of feasibility, economy, and practical dissemination . Interve


Melanoma incidence and mortality rates in Idaho are higher than national averages. The importance of increased awareness of skin cancer has been cited by state and local organizations. St. Luke’s Mountain States Tumor Institute (MSTI) prioritized educational outreach efforts to focus on the implementation of a skin cancer prevention program in rural Idaho.As a community cancer center, MSTI expanded cancer education services to include dedicated support to rural communities. Through this expansion, an MSTI educator sought to partner with a community organization to provide sun-safety education. MSTI selected, adapted, and implemented an evidence-based program, Pool Cool.The education program was implemented in 5 phases. In Phase I, we identified and recruited a community partner; in Phase 2, after thorough research, we selected a program, Pool Cool; in Phase 3, we planned the details of the program, including identification of desired short- and long-term outcomes and adaptation of existing program materials; in Phase 4, we implemented the program in summer 2012; in Phase 5, we assessed program sustainability and expansion.MSTI developed a sustainable partnership with Payette Municipal Pool, and in summer 2012, we implemented Pool Cool. Sun-safety education was provided to more than 700 young people aged 2 to 17 years, and educational signage and sunscreen benefitted hundreds of additional pool patrons.Community cancer centers are increasingly being asked to assess community needs and implement evidence-based prevention and screening programs. Clinical staff may become facilitators of evidence-based public health programs. Challenges of implementing evidence-based programs in the context of a community cancer centers are staffing, leveraging of resources, and ongoing training and support. Melanoma incidence and mortality rates in Idaho are higher than national rates; thus, skin cancer prevention education has been cited as both a regional and local priority . This prCommunity outreach and engagement to implement evidence-based programs has been studied in the context of academic and community partnerships –7. IncreSt. Luke’s Mountain States Tumor Institute (MSTI), a 2010–2012 participant in the National Cancer Institute’s Community Cancer Centers Program (NCCCP), determined through a review of the literature that the best approach to skin cancer control was to implement an evidence-based intervention focusing on prevention in an outdoor-based recreational setting  and thatSt. Luke’s Health System is the only nonprofit health system in Idaho. It is an active member of the communities it serves, with local physicians and boards who further the organization’s mission “to improve the health of people in our region.” MSTI is southern Idaho’s largest provider of cancer services and is nationally recognized by the American Society of Clinical Oncology as a leader in cancer research. Providing advanced care to thousands of patients  at 5 locations across the region, spanning western to south central Idaho, MSTI is also Idaho’s only cancer treatment center for children.As part of NCCCP, MSTI expanded efforts to achieve the goals of reducing disparities in cancer health care and serving a greater number of medically underserved patients across the full cancer care continuum . In 2011The rural community of Payette, Idaho, was selected as the implementation site for a sun-safety educational program because of its community demographics, potential risk factors, and lack of availability of cancer prevention education programs. Payette County, Idaho, is in southwestern Idaho and borders Oregon; it has a population of approximately 22,639; 80.5% are non-Hispanic white, 27.3% are younger than 18 years, and agriculture is a primary form of employment . The perThe Payette Municipal Pool is a hub of activity for the community. It provides recreational opportunities and a convenient location for residents to learn aquatic safety. The facility has a full-sized indoor and outdoor pool, which provides a venue for exercise classes, adult lap swim, regular open swim times, and swim lessons. During the summer, swim lesson enrollment reaches up to 800 young people. Pool users come from both the city of Payette and the surrounding communities.Availability of cancer prevention programs in Payette is limited. The schools provide education aligned with the curriculum of the Idaho State Department of Education Content Standards for Health: Sun Safety  12), bu, bu12), Strengths:Help all students learn more by demanding higher student proficiency and providing effective methods to help students achieve high standards.Provide parents, schools, and communities with an unprecedented opportunity to debate and reach agreement.Reinforce the best teaching and educational practices already found in classrooms and make them the norm.Help the public and local and state educators evaluate which programs work best.Limitations:Vague and unclear standards.Careless implementation of standards, and assessment may have negative consequences for students.Impose content specifications without taking into account the different needs, opportunities to learn, and skills that may be appropriate for specific districts or regions.MSTI sought to provide focused sun-safety education to young people aged 2 to 17 years in partnership with a community organization. The implementation of an evidence-based sun-safety program in partnership with the Payette Municipal Pool accomplished the goals of providing a sun-safety program through a sustainable community partnership.The objective of this case study is to describe the process taken by MSTI to engage and partner with a community organization to implement an evidence-based sun-safety program.In 2011, after historically serving only central Idaho urban communities, MSTI expanded an existing community cancer education program to include the rural communities of southwestern and south central Idaho. Before the sun-safety program was selected, potential community partners were identified on the basis of various factors, including population served by the organization, resources available for participation in a mutual educational effort, interest in collaborating on a sun-safety program, and potential for sustainable participation for the organization and MSTI. The MSTI cancer educator applied the principles of community engagement during the identification and selection process . These pPotential partners were identified by using an asset-mapping strategy. Several organizations were especially attractive as partners because they served young people or engaged young people in outdoor activities. We approached several organizations, including athletic and faith-based organizations, to assess interest in a partnership. The Payette Municipal Pool was identified as the key community partner for southwest Idaho. We selected this organization because of the interest of pool leadership in providing sun-safety education to pool patrons. The Payette Municipal Pool had not only supportive leadership but also a history of providing sun-safety educational inservices to pool staff, in partnership with local dermatologists, and a willingness to collaborate with MSTI and support educational programs through staff time.Guide to Community Preventive Services highlights the benefits of sun-safety education for adults in recreational settings but identifies inconsistent outcomes for behavior interventions targeted to children (The children . We usedchildren . After mThe geographical service area of the MSTI community cancer education program ranges over 300 miles across southwestern Idaho and into eastern Oregon. Pool Cool was not only sustainable because of its train-the-trainer model program but it could also be implemented concurrently at multiple pool settings across the MSTI service area.First implemented in 1999 at pools in Hawaii and Massachusetts, the Pool Cool program is a multicomponent sun-safety education program designed for use at swimming pools . Its maiThe Pool Cool program teaches children about the risks of overexposure to the sun and encourages them to develop healthy habits for a lifetime. Lessons are taught in conjunction with regular swim lessons, with the Pool Cool curriculum combining education, interactive activities at the pool, and pool-wide environmental changes. The main components are the following:A lifeguard/aquatics instructor training module.A Leader’s and Decision Maker’s Guidebook for pool staff.An 8-lesson curriculum on sun safety presented by aquatics instructors.Interactive activities on sun protection conducted for children aged 5 to10 and their parents. Includes demonstrations, games, and puzzles to supplement and support the lessons.Provision of shaded areas, signage, and sunscreen dispensers at the pool.Promotion of sun-safe environments.Guide to Community Preventive Services also recommends sun-safety education for recreation staff and access to sunscreen (The unscreen .The MSTI cancer educator began development of an implementation plan. Initial steps included assessment of resources and activities necessary to implement the program and identification of expected program outputs. Short- and long-term outcomes were also identified in a logic model .Although Pool Cool is an existing research-tested program and provides the resources necessary to implement the program, including a Leader’s and Decision Maker’s Guidebook, we needed to adapt the educational and training materials to ensure the program would be feasible for the community partner . The guiWe incorporated organizational branding into the guidebook and revised it to better reflect the activities and lessons that were within the scope of feasibility. We eliminated some of the optional poolside activities described by the guidebook and retained the few that were feasible based on available pool resources. We adapted print materials and educational signage by revising text and images to increase the number of educational action items and images from the local pool. Signage was reviewed by the community partner; to assess community response before implementation, we asked community members and pool staff to provide feedback on materials.Additional adaptation included the development of a pool staff training program. MSTI is a regional oncology treatment facility, and its community cancer educators are content experts in cancer prevention and early detection opportunities. As the facilitator of the pool staff training program, the MSTI cancer educator responsible for Pool Cool implementation was a resource for not only the initial train-the-trainer session but also the duration of the Pool Cool program. Staff training for the Pool Cool program included an overview of skin cancer in Idaho, behaviors that increase and decrease cancer risk, and a review of the Pool Cool program and sun-safety lessons. Additional time was provided for pool staff to practice lessons and gain confidence in their ability to teach them. Pool staff completed retrospective posttest training evaluations to assess the benefit of the information provided.Pool Cool implementation occurred in conjunction with the opening of the outdoor areas of the Payette Municipal Pool in summer 2012. Educational signage and sunscreen dispensers were provided by MSTI, and an initial training session for 13 pool staff members took place in June 2012. An additional training session was provided midway through the summer to orient new staff to the Pool Cool program. Pool Cool lessons were provided to children and adolescents aged 2 through 17 years enrolled in swim lessons from June through August 2012.MSTI made a long-term commitment to Payette Municipal Pool to provide sun-safety education to young people. Although no formal contract was signed, both MSTI and Payette Municipal Pool are fully invested in sustaining the current role of Pool Cool in swim lessons for young people. MSTI has defined skin cancer prevention as a focused effort for community cancer education as part of NCCCP participation. MSTI intends to expand the Pool Cool program to additional facilities throughout its service area.With dedicated resources to providing community cancer prevention education, MSTI was able to provide the educational signage, sunscreen dispensers, sunscreen refills, and program incentives to pool staff and swim lesson participants. Additional resources, including staff time for training, sun-safety lessons, and installation of signage and sunscreen dispensers were provided by the Payette Municipal Pool.The primary objectives of this program were to adapt and implement a sustainable sun-safety education program for young people in a rural community and create a sustainable partnership with a community organization. Through the implementation of Pool Cool at the Payette Municipal Pool, all objectives were met. The partnership between MSTI and the Payette Municipal Pool will be a template for future partnerships for community cancer education initiatives in southwestern Idaho.During summer 2012, the Pool Cool program served more than 700 young people aged 2 to 17 years enrolled in swim lessons at the Payette Municipal Pool. In addition, hundreds of others benefited from the availability of sunscreen and educational signage at multiple locations throughout the facility. Ultimately, the greatest success was the partnership formed between MSTI and the Payette Municipal Pool. A sustainable partnership was demonstrated through ongoing staff training, commitment to support future programs in MSTI activity planning, and proposed expansion to sites in additional rural communities. Not only was this sustainable partnership formed but MSTI also successfully adapted and implemented its first evidence-based cancer control education program in a community setting.The literature has multiple examples of community-engagement activities and evidence-based programs implemented through partnerships between academic institutions and community organizations –7,18,19.Principles of Community Engagement, “partnering with the community is necessary to create change and improve health” (Community cancer centers are ideal organizations to support cancer prevention efforts. They are required to provide at least 1 cancer prevention program to maintain accreditation or become accredited by the Commission on Cancer of the American College of Surgeons. Community cancer centers are located throughout the United States in both urban and rural settings, treating 85% of those who have a cancer diagnosis . The pri health” .Throughout the implementation of Pool Cool, MSTI followed the principles of community engagement  and crea


The not-on-tobacco program is an evidence-based teen smoking cessation program adopted by the American Lung Association (ALA). Although widely disseminated nationally via ALA Master Trainers, in recent years, adoption and implementation of the N-O-T program in West Virginia (WV) has slowed. WV, unfortunately, has one of the highest smoking rates in the US. Although it is a goal of public health science, dissemination of evidence-based interventions is woefully understudied. The present manuscript reviews a theoretical model of dissemination of the not-on-tobacco program in WV. Based on social marketing, diffusion of innovations, and social cognitive theories, the nine-phase model incorporates elements of infrastructure development, accountability, training, delivery, incentives, and communication. The model components as well as preliminary lessons learned from initial implementation are discussed. A core function of public health includes developing effective interventions that address priority health issues and assuring that those interventions are disseminated widely and sustained over time , 2. AlthAttributing to this dearth of literature is the fact that little is known about effective strategies for dissemination and implementation of complex public health innovations across large health and education systems. Importantly, although dissemination research may be lacking, the public health practice literature identifies a number of impediments to the widespread dissemination of effective interventions. These include differences among delivery systems at state, regional, and local levels; the lack of a single, effective dissemination system; and insufficient organizational and personnel capacity . Other cyouth tobacco use is a chief example. As one of the most costly public health issues in the United States, cigarette smoking , the presence of a seasoned N-O-T ALA master trainer, and an established Community Partnership Board through the West Virginia Prevention Research Center (WV PRC) who can provide guidance and local support for the model. The nine-phase dissemination model builds on previous research by our team –25 and oIn 1998, West Virginia researchers and the WV PRC Community Partnership Board used community-based participatory research methods to develop a youth smoking cessation program designed for 14–19 year olds, called not-on-tobacco (N-O-T described in detail below). Following pilot testing in WV and multiple randomized trial and evaluation studies for effectiveness, the ALA adopted N-O-T as their premiere teen smoking cessation program, including a national train-the-trainer structure comprised of 10 N-O-T Master Trainers. This structure supports the implementation of a centralized dissemination model. It is currently the most used teen smoking cessation program in the nation  and has Extensively detailed elsewhere , the N-ON-O-T facilitators guide teens through each session utilizing a total health approach that focuses on healthy behaviors, stress management, and life skills. Specifically, the program includes motivational issues, smoking history, nicotine addiction, the physical, psychological, and social consequences of smoking, preparation for quitting, dealing with urges and cravings, relapse prevention, stress management, dealing with family/peer pressure, increasing healthy lifestyle behaviors in physical activity and nutrition, and volunteerism. Over a decade of published research shows that N-O-T is cost-effective , adoptabConsistent with our community-driven research approach, the investigators consulted with the WV Division of Tobacco Prevention to assess the challenges with the statewide reach of N-O-T. Subsequently, we conducted a systematic evaluation  to assesevery RESA had at least 40 trained facilitators; about 700 facilitators were trained between 2000 and 2005  in 2004 and the lowest in 2000 (n = 41) (N = 750) found that 24.1% of teens had quit smoking. Of the teens that did not quit, 67% reported smoking reduction. These quit rates are at or above national N-O-T averages, showing that WV efforts with N-O-T are positive when the program is offered. Unfortunately, our findings suggest that even in the year of our highest reach (2004), given a 29% smoking rate in WV’s 14–18 year olds), N-O-T’s overall reach among WV teen smokers was <1%.Interestingly, and 2005 . Still,  = 1,008 . N-O-T p(n = 41) . The pro(n = 41) . The meaPrevious N-O-T studies identified dissemination barriers at facilitator and teen participant levels , 41. In Diffusion Theory explains the patterns of adoption of an innovation by individuals and organizations over time and critical attributes that influence adoption. Rogers  but has not yet reached the majority of its potential users in WV. We assert that a centralized model of dissemination will enhance the dissemination of N-O-T, particularly in the areas of reach, adoption, and implementation. In the context of our WV case study, N-O-T is perceived as an improvement over existing practice (relative advantage); is perceived as easy to use (complexity); is perceived as consistent/compatible with existing values and practices (compatibility); can be modified and still be effective (flexibility); and has observable results (observability). Diffusion Theory also describes five distinct steps that characterize an implementer’s decision to adopt: (a) gains understanding of how the intervention works (knowledge); (b) forms a favorable attitude about the intervention (persuasion); (c) engages in activities that lead to a choice to adopt (decision); (d) utilizes the intervention (implementation); and (e) seeks reinforcement for implementation (confirmation). These steps are woven throughout the nine phases of the model, with the goal of continually moving stakeholders and users to adopt, implement, and sustain N-O-T.. Rogers  illustraSocial Cognitive Theory was used to address the individual decisions involved in model dissemination that could not be thoroughly addressed by the systematic institutional framework of Diffusion Theory. Thus, to ensure that our model also addresses the importance of individual behavior, key social cognitive constructs include modeling and incentives. According to Bandura  conducting formative research with prospective adopters  to understand how an evidence-based intervention  can promote stakeholder missions and increase the likelihood of adoption; (2) developing sustainable channels  to promote and implement N-O-T; and (3) improving intervention access . We also incorporate the four Ps of social marketing – product at a minimal price; maximize the places that offer N-O-T programs using regional delivery; and promote program by multiple channels at multiple levels.Finally, we apply the elements of Assumption 1: an initiator/leadership group for a given community or target population has identified teen smoking cessation as a health priority requiring intervention. Assumption 2: N-O-T has been selected as the evidence-based intervention to address the priority. Assumption 3: the initiator or leadership group has established contact with a local ALA and has (a) confirmed N-O-T availability and (b) has permission to proceed with a widespread dissemination.The N-O-T Dissemination Model is presented in Figure Infrastructure: interconnected services, facilities, and resources that are often fixed or permanent in a given state/region and are necessary for N-O-T dissemination. Infrastructure can include individuals but must be more than individuals. In WV, the major infrastructure is our 10 Tobacco Prevention Regions. (2) Implementers: individuals in a given locale who are responsible for completing assigned specific tasks relevant to implementation. Key implementers are trained, qualified persons who enable implementation by assisting with communication, linking systems, channeling resources; and acting as role model, mentor, or expert. Implementers also encourage expression of feelings and opinions, gather and dispense information, provide support, and administer incentives. Key implementers include the N-O-T Master Trainers, Regional Coordinators, and N-O-T facilitators. (3) Task accountability: all participants in the dissemination process have specified functions and tasks throughout. Each implementer is provided a Task List outlining responsibilities and is asked to sign a Memorandum of Understanding. In addition, step-by-step protocols for model implementation are provided to Master Trainers and Regional Coordinators as a part of training. (4) Training: the acquisition of knowledge, skills, and competencies to deliver the N-O-T training (train-the-trainer) and to deliver N-O-T (facilitator training). The ALA has standardized training protocols for both training levels. (5) Critical assessment: provides formative information to promote N-O-T implementation. Regional Coordinators provide multiple check-ins with facilitators following training to determine ongoing activity and levels of implementation since training. Feedback, although repetitive, is short term and intended to move non-implementing facilitators toward implementation and maintain the motivation of active implementers. (6) Intervention delivery: implementation of N-O-T as intended. (7) Incentives: consistent with Social Cognitive Theory successful dissemination requires that incentives be integrated across all model phases and be valued by recipients in order to enhance motivation. In our model, forthcoming incentives are introduced during trainings and at check-ins to motivate action and raise the expectations for reward. We employ three types of incentives: social, monetary/material, and status/power. Incentives occur at four levels within the model: (a) administratively (from the WVALA to the Master Trainer); (b) regionally ; (c) among users ; and (d) among the targets (from the Facilitator to the Teens). (8) Communication: consistent with Rogers’ theory of diffusion, communication is necessary to create and share information across users, and participants to promote mutual understanding. Social Cognitive Theory also posits that individuals need consistent feedback to maintain desired behaviors. We integrate formal  and informal (spontaneous and as needed) communication. One of the model’s most significant communications occurs between the Regional Coordinators and the Facilitators .Consistent with theory and our preliminary work, the model incorporates eight essential elements: (1) Phase 1 involves engaging major partners who are key to program uptake, implementation, and sustainability. However, it does not preclude the involvement of other partners. Major partners should be represented by one or more individuals who are key decision makers or who have immediate access to key decision makers. As described above, diffusion experts contend that it is critical to obtain early buy-in from these stakeholders by illustrating how the program or intervention: (a) is viewed as relevant and meaningful to key decision makers and their organizations and how it is compatible with organizational goals; (b) can assist the organization in meeting programmatic objectives, also compatibility; (c) is cost-effective and consistent with evidence-based guidelines, complexity, and relative advantage; and (d) provides feedback mechanisms to support a decision to sustain the intervention over time, which will increase observability , 43–46. Dissemination can be described along a continuum from no adoption to full adoption . When major partners come together with the intent to disseminate an intervention such as N-O-T, it is usually under one of several circumstances. First, they have never attempted to disseminate N-O-T broadly and want to determine the most effective strategy. Second, they have attempted some type of dissemination but uptake and adoption have had varied degrees of success in different settings and with different sites. Third, all aspects are successful. In WV, the overwhelming majority of regions had experienced the first two scenarios. As such, it is necessary to conduct a collaborative needs assessment to determine the potential dissemination impediments or catalysts, particularly as they relate to infrastructure. Notably, we had already conducted our needs assessment, previously described in the background section of this article. As discussed earlier, our preliminary data suggested that the tasks of dissemination needed to be evenly distributed across the state, without the full burden of dissemination on the single WV ALA N-O-T Master Trainer. The intended effect is a reduction in complexity of facilitator recruitment, training, reporting, and continued support, provide flexibility in program delivery, and offer an advantage in barrier reduction under the current model. In order to reduce burden on the single delivery of N-O-T facilitator training, Phase 3 addresses identification and establishment of an infrastructure within which to enhance program delivery.State-level major partner infrastructure: our current project engages the infrastructures of our major partners who provide critical assets. The WV Department of Education provides access to schools and other sites that serve teens and the Regional Coordinators, whose salaries they support; the WV Division of Tobacco Prevention provides access to expert staff; and WV ALA, provides access to a N-O-T Master Trainer, as well as other assets. (b) Regional infrastructure: often, the division of dissemination labor stops with the major partners and is assigned to one or two major partners, or even worse, one or two individuals or implementers within a state. As we have learned in WV, this strategy makes it impossible to disseminate an intervention broadly. Thus, a next step is to select a regional infrastructure. Our model proposes a regional system that equally divides dissemination labor and provides primary points of contact across the five selected treatment regions. We engaged long-time partners at the Division of Tobacco Prevention who had an existing infrastructure of Regional Tobacco Prevention Specialists (RTPS) throughout the state to act as our points of contact  in each region. However, prior to the implementation of the proposed dissemination model, the RTPS network dissolved and in order to test the model, we needed to find a viable alternative delivery method. Fortunately, we were able to establish a new partnership with WVU Extension Service 4-H Youth Development Program agents to serve as the Regional Coordinators for the project. (c) Site-level infrastructure. Site refers to the place or location of actual N-O-T delivery . Sites provide necessary implementation assets such as meeting rooms, mechanism to recruit teens, and access to facilitators. Disincentives must be removed. However, it is important to give careful consideration to the model’s impact on current duties and workload. Once an infrastructure is identified and developed, Regional Coordinators use their knowledge and connections to promote the program and train facilitators.We define infrastructure as interconnected services, facilities, and resources that are often fixed or permanent in a given state or geographic location and are necessary to support and disseminate a particular intervention. Mailbach  refers tadvertising, publicity, and personal selling of N-O-T by our major partners generally and the key implementers, specifically the Master Trainer, the Regional Coordinators, and facilitators. The model relies on principles and practices from Social Cognitive Theory, Diffusion Theory, and social marketing approaches to develop and utilize promotional concepts and techniques designed to address specific behavior change goals at multiple levels of the dissemination process. Social marketing includes the application of commercial marketing techniques to the design, implementation, and evaluation of programs to promote socially positive behavior change  outweigh costs . Incentives for program adoption and implementation are provided by state-level infrastructure; Place: N-O-T facilitator training and N-O-T delivery occurs locally (is accessible); Promotional materials: N-O-T provides ready materials including testimonials, brochures, flyers, PSA/media announcements, recruitment posters, and practitioner-friendly summaries of evidence-basis. Once program promotion is underway, Regional Coordinators with assistance from the State Coordinator can conduct training with potential N-O-T facilitators. In accordance with the RE-AIM framework, the number of potential implementation sites in this phase is used to determine the denominator of the program reach.Dissemination and marketing theories align with relative advantage of Diffusion of Innovations theory and suggest that dissemination of a public health program is maximized when potential adopters are: (a) aware of a public health need, (b) are aware of evidence-based, cost-effective approaches to address that need, (c) perceive that a particular program has advantages over other options for addressing the need; (d) perceive organizational and target population benefits to program adoption where benefits outweigh costs, and (e) have the capacity to implement the intervention , 47, 48.r change , 50. Forr change : ProductTrain-the-Coordinator: in the case study, the WV ALA N-O-T Master Trainer trains all five Regional Coordinators on model implementation with supplemental training on the roles and responsibilities of the Regional Coordinators, communication, and documentation conducted by research team staff. Training occurs over 2 days, including the regular N-O-T facilitator training and an intensive training on Regional Coordinator responsibilities. Facilitator training: for our study, the Regional Coordinators conduct facilitator training according to ALA guidelines with additional information about research protocols at the end of the training. Facilitators who are interested in participation in the study complete an informed consent document related to the enhanced communication schedule and human subjects’ protection. Per ALA N-O-T protocol, facilitators receive a copy of the curriculum, and didactic and experiential instruction on the N-O-T curriculum. Training lines up with the five distinct steps of adoption described in Diffusion of Innovations theory: knowledge, persuasion, decision, implementation, and confirmation. Training also applies knowledge gained in Phase 2 to identify appropriate incentives  to induce adoption and maintenance. Training also is tailored to address some of the key issues identified in our needs assessment, including negotiating with administration and other school personnel regarding time and resources, and teen recruitment. It is important to hold trainings at a place of convenience, as determined by our partners. All trainings are evaluated, per N-O-T protocol. In order to assess whether the issues identified in the needs assessment are being adequately addressed, we established set check-ins throughout the entire adoption process including, N-O-T teen recruitment and implementation. This allows for quick response and flexibility if a trained facilitator reports a barrier at any stage of adoption and implementation. The number of facilitators trained in Phase 5 serves as the numerator for determining reach.All of our trainings follow standardized protocols. During training, all implementers receive their Task Lists, Memorandum of Understanding, and Step-by-Step Protocols for Delivery. Regional Coordinators have task accountability for checking in with N-O-T facilitators within 3 months following N-O-T training. Monitoring: Regional Coordinators monitor facilitators by collecting process and outcome evaluation data, with emphasis on implementation impediments/enhancers and teen recruitment. It is expected that at 3 months post training facilitators should have either begun implementation of their first N-O-T offering or begun planning for implementation. Standard data collection tools are used for Check-ins. Key Check-in queries include: has a N-O-T offering been scheduled, what recruitment methods are being used, what barriers/enhancers have been encountered, what potential solutions have been identified? N-O-T facilitators have the option of accessing the reporting forms electronically (via the Internet) or through the mailed survey forms . Reporting: normally, the Regional Coordinators are responsible for collecting data and reporting findings to the ALA and the evaluators. In our study, the WVU research team works with the Regional Coordinators to sort and analyze the collected data as part of each Check-in. Mentoring: mentoring reflects the data collected through monitoring. Regional Coordinators provide positive feedback or praise to the facilitators who have either begun a N-O-T program or have one scheduled. Regional Coordinators also reinforce implementation of the standard N-O-T curriculum and assist with any necessary tailoring for N-O-T given their site needs. The Regional Coordinator facilitates problem solving with the cohort of facilitators through a Listserv and links facilitators to other facilitators in or outside of the cohort. Note: mentoring is a form of communication that is a crosscutting essential model element; thus, it is on going  as well as during check-ins . Incentives: all newly trained Facilitators receive a certificate of completion from the Regional Coordinators. At this point, the incentives are at social and status levels. The incentives for the 6-month Check-in are introduced at this time to motivate facilitators to action.This model intends that N-O-T is delivered as prescribed in the N-O-T curriculum. Facilitators have the task accountability for recruiting youth and delivering the program. It is expected that each facilitator implement >1 N-O-T offering within 6 months of training; >2 within 12 months. The N-O-T curriculum provides extensive detail on recruitment and implementation; however, Regional Coordinators assist facilitators with any implementation challenges during Check-ins. The sites for implementation are linked to the trained N-O-T facilitators – in WV, there are over 300 potential sites across regions. To address recruitment and other barriers identified in our preliminary studies, our goal is to provide ongoing mentoring and technical assistance to facilitators, enhance training on recruitment, and tailor promotional materials. Adoption and implementation are in accordance with the assessed as the number of N-O-T programs successfully offered to teens.problem solving with non-implementers. Reporting: (see Phase 6). Mentoring: coordinators provide positive feedback or praise to the facilitators who completed a N-O-T offering; coordinators troubleshoot with those who did not. Incentives: facilitators who completed a N-O-T offering receive a monetary incentive of $250 (paid by the ALA). They also receive a certificate of completion. Facilitators who complete >1 N-O-T offering within 6 months are awarded a “bronze” status, a way of recognizing experienced N-O-T facilitators.Monitoring: as in the 3-month Check-in, Regional Coordinators monitor facilitators by collecting process and outcome evaluation data, impediments to implementation, and youth recruitment. It is expected at 6 months post training that N-O-T facilitators should have completed one N-O-T offering. The 6-month Check-in includes a Critical Assessment , 52 thatproblem solving with non-implementers. Reporting: in the proposed study, the WVU research team assists the Regional Coordinators with collecting the data and analyzing the findings. Mentoring: Regional Coordinators provide positive feedback to the facilitators who have completed a N-O-T program. The Regional Coordinator encourages non-implementers to offer N-O-T within 3 months and assists with troubleshooting. The Regional Coordinator continues to reinforce the ALA’s implementation protocol. At the end of Phase 9, the cohort of active facilitators that trained together is linked to the regional N-O-T facilitator network for future support and communications. Facilitators who have not implemented a N-O-T offering exit out of the model and are not be included in the regional network. Incentives: facilitators who complete a N-O-T program receive a monetary incentive of $250. In addition, they receive a certificate of completion. Continuing from the 6-month Check-in, Facilitators who complete >1 offering receive “bronze” status. Those who complete the N-O-T program >2 times receive “silver” status. Facilitators who complete >4 receive “gold” status.Monitoring: as in the 3- and 6-month post training check-ins, Regional Coordinators monitor N-O-T facilitators by collecting process and outcome evaluation data, with emphasis on impediments to implementation and recruitment. It is expected that N-O-T facilitators have, at the very least, completed one N-O-T offering. Key queries include: did they implement the program, did they follow protocol, what barriers did they encounter, how many teens enrolled, how many teens attended or completed N-O-T, what quit or reduction outcomes were found? Facilitators are also asked for input on program improvements. Again, facilitators may access reporting forms electronically or through the mail. The 12-month check-in is a Critical Assessment to identify if the facilitator has conducted a N-O-T group. Again, Regional Coordinators engage in design a randomized controlled trial to examine the following aspects of the dissemination model: reach into the target population; Effectiveness of the intended intervention; Adoption by target settings; Implementation and consistency of delivery; and Maintenance of use or effects over time  who provided guidance in the model structure, potential incentives, and assisted in troubleshooting challenges as they arose. Specific to this project, these relationships were invaluable when a critical component of the model, the RTPS network, dissolved. Community and organization partners helped to identify a new and equally viable option, the WVU Extension Service. This change created delays specifically in Phase 4 of the model, but also allowed for new partnerships to emerge.In applied science, particularly implementation and dissemination science, feedback from trusted partners (and partners who trust you) and those who will actually implement the program is critical to disseminate programs to scale. Although building relationships and trust takes time, in order to develop an intervention and dissemination plan, it is important to involve stakeholders and intended adopters early in the development process to provide feedback about viability, the socio-political context in which the intervention is to take place, work flow, resources, communication channels, and reporting (what and to whom).Also, a lesson from this project that could be applied broadly to dissemination science is the critical link between researchers and practitioners. These linkages allow for honest feedback about what is working in the field and allow researchers to make timely adjustments to components of the model and assess progress. In addition, this project is unique in that the Regional and State Coordinators are not just program implementers, but also research participants. They, too, are providing data to assess the model. This distinctive relationship allowed Coordinators to provide feedback at the assigned checkpoints, but to also participate in research meetings. This relationship was carefully navigated at the beginning of the project, but proved invaluable as the need to self-reflect and make adjustments allowed the project to move forward.Although it is important to maintain consistency and model fidelity when testing a dissemination model for effectiveness, it is equally important to understand that in real world settings, events happen that may alter the best laid plans. Within the first 3 years of this project, there were multiple staff changes at each level of the model. This was a major challenge that required time for each of the new staff to learn their roles and develop the relationships discussed above. In the field, these staffing challenges primarily affected Phase 4 of the model, “Promote the Intervention,” because each new staff member had to reestablish community connections in order to create buy-in for the intervention.Changing political environments, increased demands on school personnel time, and health priorities in schools away from tobacco interventions created situations in which the traditional model of delivery for the not-on-tobacco program were more difficult. In order to address these changes, this model explored alternative delivery methods and new partnerships, specifically in community organization settings that serve youth. This flexibility allowed for the program to grow beyond the school setting and created opportunities for new and important partnerships that did not exist previously. We also decided to expand the program to facilitators in the treatment regions who were previously trained by the WV ALA. To reduce burden on these currently trained facilitators, research staff worked with the State Coordinator and Regional Coordinators to create an Online training module and consent form for those who wanted to participate in the research study.As with many programs over the last decade, this project faced funding challenges that required adjustments in scope. Because of delays due to noted infrastructure challenges, funding cut backs, and staffing challenges, the scope of the program was scaled back to incorporate two treatment regions with which we could work closely and really try to understand the mechanisms that led to barriers and successes within the model structure.The built-in feedback loops in the model allowed for Regional Coordinators and the State Coordinator to provide insight into recruitment strategies in the field that were not necessarily envisioned by research staff. This included recruitment materials such as posters and pamphlets, channels such as social media and committee meetings, and potential facilitators from community organizations that were unknown to research staff during the planning process (Phases 1 and 4). In addition to the reactive dissemination channels described above, research staff provided proactive information that users may not know to request but that they are likely to need. They also indicated that the incentives built-in to the model were not sufficient to overcome some of the same challenges identified to facilitators in the needs assessment phase of the model, the most prominent of which remained, lack of time to implement the program.The final lesson learned thus far is the critical importance of consistent communication among all levels of the research team. Consistent meetings of a core research team allowed for timely decisions and protocol adjustments as challenges arose. In addition, the research team asked for assistance, insights, and recommendations from the WV Prevention Research Center (PRC) Community Partnership Board throughout the life of the project.out in the field much of the time. Because they serve very rural areas of the state of WV, they often did not have cell service or access to the Internet, making communication and reporting difficult. However, the built-in check-ins often corrected for this and allowed for communication among research staff, the State Coordinator, and Regional Coordinators.A major challenge with the current model was embedded in the nature of the additional scope of work required by our WVU Extension Service Regional Coordinators. Our Extension partners were It was critical throughout this process to be in constant communication with key partners identified both in Phase 1, and new partners identified in Phases 3 and 4 to provide updates, solicit feedback about potential adjustments to the protocols, and identify and address barriers to success. Finally, research staff kept the funding agency apprised of all changes throughout the process to ensure that the goals of the project were fulfilled to their satisfaction.The present model is among the first field-tested dissemination models of an evidence-based teen smoking cessation intervention. The nine-phase model has a sound theoretical foundation utilizing critical constructs in intervention diffusion, health behavior, and social marketing. The development and first years of implementation illuminated key lessons that are applicable beyond teen smoking cessation programs. Although the final outcomes of this model are not known, several of the key lessons can be applied to dissemination science beyond a teen smoking cessation programing. A main focus of the present model is to de-centralize responsibility and allow for a local locus of control . The intent is to better meet the needs and challenges of N-O-T facilitators and teens at the local level, while maintaining fidelity to an evidence-based program statewide. In this WV example, this de-centralization used state-level coordination to guide and support the new structure while working to eliminate some of the burden of recruitment, communication, and record keeping associated with not-on-tobacco program evaluation locally. It also served to create new partnerships and highlighted the need for flexibility and multiple channels and levels of communication across numerous stakeholders.Kimberly Horn conceived the study, drafted the majority of the manuscript, and provided critical content review and final revisions. Traci Jarrett also made substantial contributions to the manuscript and implemented the study. Andrew Anesetti-Rothermel and Nancy O’Hara Tompkins assisted in data interpretation and provided revisions. Geri Dino made substantial contributions to the conception and design of the study.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Authors Horn and Dino are co-developers of N-O-T; however, the American Lung Association owns all copyrights and the developers have no rights to ownership and receive no financial remuneration for program use or distribution.