Study site

The original research plan was to implement FOYC+CImPACT with enhanced implementation strategies nationwide in the 2019–2020 school year. Because of the damage caused by Hurricane Dorian and the school closures related to the COVID-19 pandemic, it was decided that implementation in the Family Islands would begin in the 2020–2021 school year, resulting in two waves of implementation: wave 1 in New Providence and wave 2 in the Family Islands. Thirty-four elementary schools in the Family Islands of The Bahamas participated in the second wave of the national implementation of FOYC+CImPACT in the fall of 2020. A total of 47 Grade 6 teachers and 984 students participated in the study. The research protocol was approved by the UMass Chan Medical School Institutional Review Board and the Institutional Review Board of the Bahamian Princess Margaret Hospital, Public Hospitals Authority.

FOYC+CImPACT program

Teachers implemented the 8-session FOYC adolescent HIV prevention curriculum in Grade 6 classrooms. The curriculum includes 30 core activities. FOYC is incorporated in the Health and Family Life Education (HFLE) curriculum for The Bahamas. The CImPACT parental monitoring intervention is a single session (with 5 core activities) between parents, students, and teachers. School coordinators provided teachers BMF, and high-performing teachers acted as peer mentors to provide SAM; these enhanced implementation strategies were chosen based on empirical evidence that implementation monitoring and feedback as well as mentorship and coaching are effective strategies to promote implementation fidelity [7]. They were developed with the local research team and teachers to be culturally sensitive and to address inner and outer contextual factors of the EPIS framework. Further, school coordinators communicated with the FOYC research team to identify issues that could be addressed by leaders and policies (e.g., online data collection) in the outer context. These enhanced implementation strategies were shown to be effective for supporting FOYC implementation fidelity prior to waves 1 and 2 of the national implementation and have been described in detail elsewhere [19]. Initially, each school was supposed to be assigned a school coordinator and have mentors. However, because of barriers imposed by the crises, only 32% of schools had coordinators, and only 24% had mentoring teachers for the 2020–2021 school year.

Teacher training

Typically, the annual FOYC+CImPACT teacher training workshops were two-day, in-person sessions led by three Bahamian FOYC trainers and a US training specialist with extensive experience with FOYC+CImPACT. The training followed FOYC guidelines and consisted of clear objectives, short lectures, interactive group discussions, videos, demonstrations of curricula activities and skills, skill practice, role play, and teach backs [22]. The workshop aimed to increase participants’ curriculum knowledge, strengthen teacher attitudes about the positive effects of the curriculum, and improve teachers’ skills and comfort with the curriculum. Specifically, teachers (1) reviewed the need for HIV prevention in The Bahamas, (2) received an overview of FOYC+CImPACT and its past efficacy, (3) observed models of the 30 core activities in the eight sessions of FOYC, (4) participated in a didactic question-and-answer period about puberty and contraception and condom use, (5) observed a model of CImPACT, and (6) received in-depth skill instruction and practice teaching one or more core activities with live feedback. Teachers also received examples of approaches to address the curriculum in their classrooms, as well as copies of the FOYC teacher training manual and FOYC+CImPACT 24/7 flash drives for remote, digital “point-of-care” implementation guidance.

In the fall of 2019, 33 teachers completed the training workshops in Grand Bahama prior to the arrival of Hurricane Dorian. After the hurricane and then the onset of the COVID-19 pandemic, all trainings and plans for implementation of the curriculum in the Family Islands were suspended until the 2020–2021 school year.

Teacher training webinars for 2020–2021 school year all took place synchronously on a virtual platform. Twenty-eight Family Island teachers registered for the webinars in advance and completed the pre-workshop measures and consent. The webinars consisted of three 2-h sessions, which consisted of live, instructor-led trainings designed to provide new FOYC teachers with relevant curriculum information and resources required to implement FOYC+CImPACT. Trainers modeled the core activities and sessions of the curriculum. Teachers also received a summary of the FOYC efficacy research and a situational analysis of HIV/AIDS and teen pregnancy in The Bahamas. Trainers conducted didactic and interactive sessions to increase teachers’ comfort levels with the material and answered sensitive questions that could arise in the classroom. Teachers received an electronic copy of the manual and resources. Teachers could access recordings of the webinars to review the sessions, and teachers who were unable to attend had access to the recordings.

School coordinator and mentor training

A school coordinator was identified for 11 of the 34 schools to complete BMF. Most of the coordinators were guidance counselors or vice principals who oversaw all Grade 6 HFLE teachers within a school and could coordinate between classrooms and monitor activities. Teachers’ implementation and progress were monitored biweekly over the course of the school year via a standard form where coordinators noted the date(s) of the sessions, how many core activities were completed, recorded notes for the teachers to review as feedback, and noted any issues teachers have had (such as scheduling or difficulty translating particular core activaties to virtual formats) to report to the FOYC research office. Eight high-performing teachers and guidance counselors provided SAM to at-risk and moderate-performing teachers who had been identified by their responses on our validated Pre-implementation Screening Tool [23] and their implementation performance in the past year. Mentors were trained to identify challenges, assist teachers in preparing sessions, model how to teach the core activities, and provide guidance for curriculum delivery. Four Bahamian trainers with extensive experience with FOYC+CImPACT conducted 2- to 3-h training sessions with school coordinators and mentors in 2019.

MeasuresImplementation fidelity

Implementation fidelity was defined as number of the 35 core activities of the curriculum taught. The degree of implementation was the number of the nine sessions covered. Teachers completed a Teacher Implementation questionnaire specific to the FOYC+CImPACT sessions following each session. They documented the activities covered in each session, their degree of comfort with the session (very comfortable, somewhat comfortable, and not comfortable at all), whether they taught the activities as outlined in the manual or made any modifications to the format of activities in the manual, and how many students (most, some, few) seemed engaged in the session.

Teachers’ characteristics, training experience, and perceptions

Most teachers (n = 45) completed a pre-implementation questionnaire to provide information known to affect implementation fidelity [23]: level of formal education; years as a teacher; attendance at the training workshop, either in years past or for the current school year; perceptions of the importance of HIV prevention (“very meaningful” to “not at all meaningful”) for Grade 6 students; comfort level teaching the FOYC+CImPACT curriculum; and any competing lessons or teaching priorities. The pre-implementation questionnaire consisted of four items assessing teachers’ perceived principal supportiveness (e.g., “My principal is supportive of teaching FOYC”) [24, 25]; eight items assessing teachers’ attitudes toward sex education in schools (e.g., “Young people are given too much information on sex”) [26]; three items assessing their self-efficacy in teaching the FOYC+CImPACT curriculum (e.g., “I feel like I can teach the FOYC+CImPACT program according to the manual”) [27]; four items assessing teachers’ autonomy in their classroom (e.g., “I determine norms and rules for student behavior within my classroom”) [28]; and five items assessing teachers’ confidence teaching five topics: condom use, teen pregnancy, alcohol and drug use, sexual harassment/abuse, and HIV/AIDS [29]. Each item used a 5-point Likert scale (1 = “totally disagree” to 5 = “totally agree” for principal supportiveness, attitudes toward sex education, self-efficacy, and autonomy and 1 = “not at all confident” to 5 = “very confident” for confidence). The internal consistency (Cronbach’s α) of the scales is adequate (principal supportiveness, α = 0.77; attitudes toward sex education, α = 0.72; self-efficacy, α = 0.73; autonomy, α = 0.77; confidence, α = 0.85).

The national coordinator and The Bahamas’ FOYC project manager, as well as FOYC curriculum trainers, assessed the performances of school coordinators and mentors with a brief survey. The survey evaluated 14 items as “unsatisfactory,” “satisfactory,” “good,” or “excellent,” including coordinator’s knowledge of the FOYC curriculum, communication with the research office, perception of leadership, submission of measures, number of sessions mentored, and whether the mentor was remote or site based. Assessors also noted school coordinators’ and mentors’ performance via free responses.

Student outcomes

Students completed an anonymous curricular assessment instrument, adapted by the MOE from a version of the Bahamian Youth Health Risk Behavioral Inventory [30], prior to experiencing FOYC in grade 6, and they repeated the assessment at the end of Grade 6 (6 months after exposure to the curriculum). Their data were deidentified and aggregated by classroom and then linked to teachers’ performances. The instrument assessed HIV/AIDS knowledge, preventative reproductive health skills, and students’ perceptions of self-efficacy, intentions, and self-reported behaviors. HIV/AIDS knowledge was assessed via 16 “true or false” statements. Preventative reproductive health skills were assessed with an adaptation of the Condom-use Skills Checklist [31], which consisted of six true or false statements that describe correct condom use. Students’ self-efficacy to practice safe sex was assessed with five items on a 5-point Likert scale (1 = “strongly disagree” to 5 = “strongly agree”), and the mean was used as a composite score. The internal consistency of the scale was 0.78. Intention to use condoms for protection was assessed with a question “what are the chances that you would use a condom if you need to prevent yourself from getting HIV” and which students ranked on a 5-point Likert scale (1 = “no chance in the world” to 5 = “yes, big chance that I would”).

Analysis

First, frequency distributions summarized the number of sessions taught (of the nine possible) and the number of core activities completed (of the 35 possible). Second, to identify factors associated with teachers’ fidelity of implementation, we used ANOVA (and Student’s t-test) to relate the number of core activities and the number of sessions taught to teachers’ personal characteristics, training experience, and perceptions. We also examined association of initial teacher training (in-person, online, and both) and continued implementation support (implementation monitoring and peer mentoring) with implementation fidelity. Third, we examined the difference between baseline and follow-up in students’ HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection (using Student’s t-test). The test statistics were adjusted for the clustering effects of classroom and/or school using variance inflation factors (VIFs). The analyses used SAS 9.4 statistical software (SAS Institute Inc., Cary, NC, USA).