Discussion
fits, RCL
PMT
This study assessed implementation of the RCL program as part of a randomized controlled trial and sought to assess the three components of dosage: duration and amount as well as fidelity and quality. Results suggest the program was implemented with high quality and fidelity and provides guidance for other tribal communities planning to implement RCL. Additionally, we found no relationship between PMT dosage amount and intention outcomes, suggesting that perfect attendance was not imperative for the intervention to have positive effects.The high fidelity and quality of the intervention as it was delivered, namely the delivery by local paraprofessionals from the community, are promising for replication and sustainability in Native communities. These results indicate high fidelity to the intervention does not require facilitators to have an advanced degree or formal teaching experience outside of training in the RCL curriculum. While likely no formal education is required to facilitate RCL, sufficient training including at the minimum a week-long training in addition to extensive practice through roleplays is necessary. Replication efforts for RCL should include ample budget and time to provide this training and time to practice.It is encouraging to observe the high rates of fidelity and quality reported by facilitators through the facilitator self-assessments were mirrored in the observation forms, which were completed by independent observers. Often, there are concerns about self-reported fidelity because facilitators may be influenced by social desirability and, thus, may provide inflated reports of fidelity (Gresham et al., With an average completion of 80% of lessons, findings also suggest delivering RCL with increased frequency but reduced duration, specifically, through an 8-day basketball camp followed by a home-based parent-youth lesson, results in high levels of intervention received (amount). While we did not collect data on the impact of the retention efforts that we made (see Tingey et al. (Given the difference in attendance (and overall amount of intervention received) between the cohorts, specifically that in cohort 1, the two lessons taught on the weekend (lessons 2 and 3) had substantially lower rates of attendance compared to other cohorts; findings indicate future replication of RCL should avoid delivering lessons on the weekend and thus extend the 8 peer-lesson duration from 8 consecutive days to 10 days with a break on the weekend. Additionally, the significantly higher rate of parent-youth lesson completion in cohort 1 coupled with the significantly longer duration between the last peer group lesson and the parent-youth lesson indicates that spreading the parent-youth lesson out from the last peer group lesson may be advantageous as far as increasing level of completion of the parent-youth lesson. Due to the small sample size across cohorts and the lack of randomization for the timing of the intervention or cohort, we are unable to ascertain if the increase in time between the peer group lesson and the parent-youth lesson impacts outcomes in a positive or negative way. The impact of duration on outcomes should be assessed in future trials of RCL.It is promising that we did not see significant variations in amount of intervention (specifically PMT construct amount in min) received by age or sex—suggesting the RCL program when delivered to youth of the same sex and age group is appealing and engaging for all youth aged 11–19. There was some hesitancy by facilitators to engage the younger youth in this program, however, based on the lack of differences in dosage across age combined with high fidelity across lessons indicates RCL is appropriate for this age group. This may be due to the fact that RCL provides opportunities for the facilitators to tailor the curriculum by sex and age—a key concept that may have contributed to the lack of differences by these characteristics. Many lesson activities that include examples of situations youth may find themselves in are not “one-size fits all.” There are multiple examples, and thus, the facilitator can choose one that seems to best reflect the sex and experiences (or age) of the group members. Regardless of why, that the RCL program seems to appeal to youth of all ages and sexes is promising as boys, particularly older boys, are often harder to engage and retain in programming (Walker et al., The lack of significance seen between primary outcomes and PMT dosage may be somewhat impacted by the large proportion of youth who received 100% of all PMT construct dosage amount or the small sample size. It most likely means that complete dosage of the program is not necessary to see positive impact on primary outcomes and is a strong contribution to the literature specific to teen pregnancy prevention in Native communities. This result is also promising for replication of the program in real-world settings as it may be assumed that unlike this research trial in which resources were not significantly constrained, in resource-constrained communities, it may be harder to attain the high level of attendance/dosage amount as seen in this trial. This analysis was limited in that we cannot ascertain what level of PMT construct dosage is optimal for the best outcomes, and future studies of RCL should aim to include a large enough sample size to conduct this analysis and/or randomly assign youth to certain amounts of the intervention.