Adult Behavior Change: A Prerequisite for High Levels of Treatment Integrity in Schools

Lisa M. Hagermoser Sanetti1, Anna C. J. Long1, & Thomas R. Kratochwill2 1University of Connecticut, University of Wisconsin-Madison2

The proper implementation of school-based interventions requires adequate levels of treatment integrity (Noell, 2008), yet treatment integrity levels of most school personnel decline shortly after training (e.g., Sanetti, Fallon, & Collier-Meek, 2011). Although the implementation of most school-based interventions requires adult behavior change, there is a dearth of research in school psychology; thus, systematic research from other fields should be considered. The Health Action Process Approach is an empirically supported behavior change theory (Schwarzer, 1992), which aligns well with current conceptualizations of treatment integrity and educational practice (e.g., Gresham, 1989; Sanetti & Kratochwill, 2009). Based on this theory, researchers from the University of Connecticut and University of Wisconsin-Madison are developing a system of supports to facilitate teachers’ implementation of interventions within a consultation model (i.e., Planning Realistic Intervention Implementation and Maintenance by Educators; PRIME). This poster describes (a) the Health Action Process Approach and its applicability to education, (b) the components of PRIME, (c) PRIME within in a consultation model, and (d) future research directions.

Introduction

. Health Action Process Approach

PRIME materials have been developed through a year-long process, including initial development, feedback from experts and stakeholders, and final development. For the next 2 years, these materials will be evaluated using a series of single-case designs. The goal of these evaluations is to pilot, refine, study, and finalize PRIME assessment and intervention components such that they (a) appropriately assess teachers’ intentions and self-efficacy, (b) result in increased treatment integrity in the short- and long-term, (c) are implemented with a high level of treatment integrity, and (d) have a positive effect on student outcomes.   

PRIME in a Consultation Model• Assessment of Implementation Intention: The

Implementation Intention Assessment measures consultees’ perception of a problem, positive outcome expectations, and implementation self-efficacy. Results of this assessment will help identify consultees with (a) high levels of implementation intention who are ready to develop an Action Plan and (b) low levels of implementation intention who would benefit from additional support.

• Strategies to Increase Implementation Intention: Consultees with low implementation intention will receive targeted support. Depending on their low implementation area (i.e., perception of the problem, positive outcome expectations, and implementation self-efficacy) one of seven best- practice strategies to increase a consultee’s implementation intention will be employed. These strategies address one or more components of implementation intention and are feasible within school settings.

• Action Plan: When consultees have high implementation intention they will complete an Action Plan. The Action Plan facilitates detailed logistical planning of implementation in a school setting.

• Maintenance Plan: In addition to the Action Plan, consultees also develop a Maintenance Plan. The Maintenance Plan promotes the identification of barriers that might inhibit a consultee’s ability to maintain intervention implementation.

• Assessment of Sustainability Self-Efficacy: To promote sustained intervention implementation, consultees’ sustainability self-efficacy will be regularly assessed. Sustainability self-efficacy is a consultee’s confidence in his or her ability to (a) maintain a behavior (i.e., maintenance self-efficacy), and (b) resume the behavior after interruption (i.e., recovery self-efficacy).

• Strategies to Increase Sustainability Self-Efficacy: Consultees with low sustainability self-efficacy will receive targeted support. Depending on whether a consultee is low in maintenance self-efficacy, recovery self-efficacy, or both, one of four best-practice strategies to address his or her sustainability self-efficacy will be employed.

To guide the development of PRIME, researchers turned to a related field (i.e., health psychology) for an empirically supported model of behavior change, the Health Action Process Approach (HAPA; Schwarzer, 1992). The HAPA is an empirically supported behavior change theory, which distinguishes between a motivational stage (i.e., when one develops an intention to change their behavior) and a volitional stage (i.e., when one adopts and maintains new behavior; Schwarzer, 1992).

The HAPA is well suited to apply to treatment integrity conceptualizations in educational research and practice, as it is based on social-cognitive theory, which is well supported in education (Bandura, 1997), aligns well with conceptualizations of treatment integrity (e.g., Gresham, 1989), addresses the intention-behavior gap, which has been documented as difficult for teachers implementing interventions (e.g., Noell et al., 1997; Sanetti & Kratochwill, 2009), and provides individual ongoing support along the intention-behavior-initiation- maintenance continuum.

PRIME Components

intention is employed. When assessment results reveal all components of implementation intention to be adequate, Action and Maintenance Plans are completed.

• Then the consultee will implement the evidence-based intervention. After a period of time, the consultee will complete the Sustainability Self-Efficacy Assessment. If results for maintenance or recovery self-efficacy are low, a strategy to increase the consultee’s sustainability self-efficacy is employed. If the Sustainability Self-Efficacy Assessment results reveal both components of self-efficacy to be adequate, the consultee will continue with intervention implementation. Action and Maintenance Plans may be updated as needed during intervention implementation.

• During Stage 5: Plan Evaluation, a consultant and consultee may decide that the intervention needs to continue as developed or needs to be modified to meet the student’s needs. If the latter occurs and the intervention changes substantially, it may be appropriate to begin the PRIME process again, assessing implementation intention for the new intervention. If the prior intervention is only modified, it may be appropriate just to update the Action and Maintenance Plans as needed.

Future Directions

Project PRIME is supported by a grant provided by the Institute for Education Sciences, U.S. Department of Education (USDOE; R324A100051). Opinions expressed herein do not necessarily reflect the position of the USDOE, and such endorsements should not be inferred.   

· Development of trusting, genuine, open relationship with consultee

· Communication of awareness of issues of concern to consultee

Stage 1: Establishing Relationships

· Describing and defining student problem to be addressed

· Determining times, dates, formats for subsequent consultation sessions

· Establishing assessment plan

· Developing understanding of needs related to student social and academic competencies

Stage 2: Problem Identification

· Identifying conditions under which problems occur

· Establishing procedures to evaluate student outcomes and intervention implementation

· Developing a plan to be implemented including who is responsible and the conditions under which the plan will be implemented

· Identifying skills to be increased

· Choosing strategies for analyzing assessment data

Stage 3: Problem Analysis

· Training consultee to implement intervention

· Selecting an appropriate research-based intervention

Stage 4: Plan Implementation

· Monitoring student outcomes and treatment integrity

3. & 4 Action and Maintenance Plans

completed with Consultee

High II

2. Implementation of Implementation Intention

Strategies

Low II

1. Assessment of Consultee’s Implementation

Intention

Low SE

Stage 5: Plan Evaluation

· Determine if goals of consultation are met, intervention needs to continue as developed, or needs to be modified to meet the student’s needs.

6. Implementation of Strategies to Increase

Sustainability SE

High SE

5. Assessment of Consultee’s Sustainability Self-Efficacy

Update Action Plan

Inte

rven

tion

adju

sted

Update Maintenance

Plan

New barrier

identified

· Implementing the chosen intervention

Note: Consultation activities in gray boxes, PRIME activities in white boxes.

• PRIME can be implemented in varied models of consultation, a frequently used method for delivering intervention services in schools. It is described here within the five stages of problem-solving consultation (i.e., establishing a relationship, problem identification, problem analysis, plan implementation, and plan evaluation; Kratochwill, 2008). No PRIME activities occur during the first three stages of consultation.

• During Stage 4: Plan Implementation, an appropriate evidence-based intervention is selected and the consultee is trained. Then, PRIME activities begin. The consultee completes the Implementation Intention Assessment. If results indicate a low level of perception of a problem, outcome expectations, and/or implementation self-efficacy, a strategy to increase the consultee’s implementation