Organizational Capacity for Sexual Assault Prevention Within a U.S. Army Installation.

INTRODUCTION: Preventing military sexual assault (SA) is a DoD priority. Building prevention capacity could strengthen the impact of prevention programs and improve outcomes. Capacity was conceptualized as implementation knowledge and skills using the Getting To Outcomes (GTO) process and organizational-level capacities using the Prevention Evaluation Framework, a framework that applies best practices in prevention and implementation science to prevention at the program and organizational level. The present study assesses implementation knowledge and skills currently possessed by SA prevention personnel in one U.S. Army installation with the goal of identifying preexisting proficiencies and potential gaps. The study uses the Prevention Evaluation Framework organizational-level domains to identify organizational capacities that could be improved. MATERIALS AND METHODS: Fifteen SA prevention program personnel were recruited for individual 1-hour interviews from one U.S. Army installation. A semi-structured interview guide was developed by the study team to assess knowledge and skills within the GTO framework. Applied thematic analysis guided data coding and analysis. RESULTS: Participants reported a range of proficiencies and gaps in capacity for SA prevention. Within the prevention workforce capacity, proficiencies were skill in tailoring training, and an existing train-the-trainer model. Gaps were training to facilitate difficult conversations, and an inability to tailor trainings to audience needs. Two proficiencies related to the comprehensive approach were having a victim advocate present during trainings, and providing training across leadership levels. The final proficiency involved data. Existing data sources were viewed as useful for identifying the nature and extent of local problems. However, participants reported a lack of confidence and skill in selecting appropriate outcome measures and collecting and using primary data. Gaps in leadership capacity were cultural norms, lack of trust, leader investment, logistical difficulty working with leaders, and comfort engaging with leaders. Gaps in collaborative relationships were the lack of informal networking within the SA prevention area to include civilians. CONCLUSIONS: The GTO-specific knowledge and skills of SA prevention personnel at one U.S. Army installation revealed proficiencies and gaps in organizational capacities influencing the prevention mission. Findings indicate that GTO support could be useful for improving the quality of program activities. However, results also indicate that GTO support would be more effective if they were paired with sufficient prevention infrastructure at the organizational level.

Using Longitudinal Surveillance of Unemployment Claims During Public Health Emergencies to Provide Timely and Granular Data on the Social Determinants of Health.

OBJECTIVE: Employment is a well-documented social determinant of physical and mental health and can be used to determine who is disproportionately affected by public health emergencies. We examined trends in unemployment overall and by gender, by race or ethnic group, and by their interaction for 2 public health emergencies (the COVID-19 pandemic and the 2020 California wildfires). METHODS: We obtained summary data files on the number of initial unemployment insurance (IUI) claims made in all 58 California counties from January 2018 through December 2021. We fit fixed-effects Poisson regression models to county data on weekly IUI claims cross-classified by gender and race or ethnic group. We used models to evaluate the overall effect of COVID-19, whether this effect changed over time increasing under compounding emergencies, and whether the overall and compounding effects of COVID-19 differed by gender and race or ethnic group. RESULTS: During the COVID-19 pandemic, weekly IUI claims rates increased to as much as 10 times their prepandemic level. The increase in IUI claims for COVID-19 weeks, compared with weeks from the same month in the 2 years prior, was greater for women than for men of all race or ethnic groups, except for Black women. The higher rates of IUI claims for most women during COVID-19 entailed a reversal of prepandemic gender differences in claims that persisted through 2021. CONCLUSION: Public health officials should consider using IUI claims for surveillance of social determinants of health, particularly in the context of emergencies, which we show can have a persisting effect on the social patterning of social determinants. Future research is needed to forecast these affects and inform public health and policy mitigation and prevention strategies.

Improving Sexual Assault and Sexual Harassment Prevention from the Bottom-up: a Pilot of Getting To Outcomes in the US Military.

While the Department of Defense (DoD) has given increased attention and priority to preventing sexual assault and sexual harassment (SA/SH), it remains a problem. To build its prevention capacity, DoD piloted Getting To Outcomes® (GTO®) from 2019 to 2022 at 10 military installations. GTO is an evidence-based planning and implementation support that has been used in many civilian contexts but has only recently been adapted for military SA/SH. The purpose of this study was to describe GTO use, identify its benefits and challenges, and discuss lessons the GTO effort yielded for prevention more broadly using a framework of organizational and program-level capacities needed for successful prevention in the military context, called the Prevention Evaluation Framework (PEF). GTO was piloted with 10 military installations ("sites") representing all Military Services, plus the Coast Guard and National Guard. GTO is comprised of a written guide, training, and ongoing coaching. The pilot's goal was for each site to use GTO to implement a SA/SH prevention program twice. Participants from each site were interviewed and data was collected on GTO steps completed, whether GTO spurred new evaluation activities and collaborations, and the degree of leadership support for GTO. Most sites completed all GTO steps at least once. Interviews showed that DoD participants believe GTO improved prevention understanding, planning, and evaluation capacity; strengthened confidence in chosen programs; and helped sites tailor programs to the military context. Barriers were the complexity of GTO, DoD personnel turnover, and the disruption that the COVID pandemic caused in sexual assault prevention program delivery. Many respondents were unsure if they would continue all of GTO after the coaching ended, but many believed they would continue at least some parts. According to the PEF, the GTO pilot revealed several additional prevention system gaps (e.g., need for leadership support) and changes needed to GTO (e.g., stronger leader and champion engagement), to support quality prevention. The military and other large organizations will need to focus on these issues to ensure prevention implementation and evaluation are conducted with quality.

Trends in 2-1-1 Calls During Public Health Emergencies, Overall and By Gender: Hurricane Irma and COVID-19 in Broward County, Florida.

Trends in 2-1-1 calls reflect evolving community needs during public health emergencies (PHEs). The study examined how changes in 2-1-1 call volume after 2 PHEs (Hurricane Irma and the coronavirus disease 2019 [COVID-19] pandemic declaration) in Broward County, Florida, varied by PHE type and whether variations differed by gender and over time. Examining 2-1-1 calls during June to December 2016, June to December 2017, and March 2019 to April 2021, this study measured changes in call volume post-PHEs using interrupted time series analysis. Hurricane Irma and the COVID-19 pandemic were associated with increases in call volume (+81 calls/d and +84 calls/d, respectively). Stratified by gender, these PHEs were associated with larger absolute increases for women (+66 and +57 calls/d vs +15 and +27 calls/d for men) but larger percent increases above their baseline for men (+143% and +174% vs +119% and +138% for women). Calls by women remained elevated longer after Hurricane Irma (5 wk vs 1 wk), but the opposite pattern was observed after the pandemic declaration (8 vs 21 wk). PHEs reduce gender differences in help-seeking around health-related social needs. Findings demonstrate the utility of 2-1-1 call data for monitoring and responding to evolving community needs in the PHE context.

Changes in Poison Center Calls for Intentional Exposure During Public Health Emergencies: COVID-19 and Winter Storm Uri in Dallas County, Texas.

OBJECTIVE: This study aimed to: (1) explore changes in the volume of calls to poison control centers (PCs) for intentional exposures (IEs) in Dallas County, Texas, overall and by gender and age, and (2) examine the association between 2 different public health emergencies (PHEs) and changes in IE call volume. METHODS: PCs categorize calls they receive by intentionality of the exposure, based on information from the caller. We analyzed data on PC calls categorized as intentional in Dallas County, Texas, from March 2019 - April 2021. This period includes the COVID-19 pandemic declaration (March 2020), a surge in COVID-19 cases (July 2020), and Winter Storm Uri (February 2021). Changes in IE call volume (overall and by age and gender), were explored, and interrupted time series analysis was used to examine call volume changes after PHE onset. RESULTS: The summer surge in COVID-19 cases was associated with 1.9 additional IE calls/day (95% CI 0.7 to 3.1), in the context of a baseline unadjusted mean of 6.2 calls per day (unadjusted) before November 3, 2020. Neither the pandemic declaration nor Winter Storm Uri was significantly associated with changes in call volume. Women, on average, made 1.2 more calls per day compared to men during the study period. IE calls for youth increased after the pandemic declaration, closing the longstanding gap between adults and youth by early 2021. CONCLUSIONS: Changes in IE call volume in Dallas County varied by gender and age. Calls increased during the local COVID-19 surge. Population-level behavioral health may be associated with local crisis severity.

Development and Pilot Test of the Competency Assessment for Sexual Assault Prevention Practitioners.

Sexual assault is a preventable problem that is widespread and particularly prevalent for certain populations (e.g., female college students, Native American women). Despite the gravity of this public health priority, most individuals tasked with the primary prevention of sexual assault are not adequately trained for the job (e.g., professionals often trained solely in sexual assault response). To achieve optimal outcomes, professionals responsible for implementing sexual assault prevention must possess certain core competencies, or knowledge and skills essential for job performance, which include those needed for any primary prevention effort in addition to those specific to sexual assault prevention. The purpose of this study was to develop and assess the construct validity of a competency assessment tool for sexual assault prevention practitioners. An existing assessment tool, which was designed for injury and violence prevention practitioners, was tailored to reflect competencies needed by sexual assault prevention practitioners as informed by the literature. The newly tailored measure was pilot tested with 33 individuals with varying levels of expertise with sexual assault prevention. These individuals were categorized into three groups based on self-rated sexual assault prevention expertise (low, medium, or high) to assess group differences. As expected, the high expertise group rated higher knowledge in all the competencies than the medium and low expertise groups (except for the competency pertaining to developing and maintaining competency). Data collection and analyses were conducted in 2020. Implications for how the assessment tool can be used to identify gaps among individual practitioners and teams of practitioners are discussed.

Scaling Up Implementation Support for Violence Prevention and Resilience Promotion in the Air Force.

Closing the gap between research and practice requires that organizations can consistently incorporate new ideas and best practices. The Department of the Air Force (DAF) Integrated Resilience Directorate is leading a coordinated effort to increase the adoption of evidence-based violence prevention and resilience promotion programs across the entire Department. To support this effort, DAF is using Getting To Outcomes (GTO), an evidence-based implementation support that helps organizations plan, implement, and self-evaluate programs. Thus, the DAF is not only scaling up prevention programs but is also embarking on the largest scale-up of GTO to date. The study team trained personnel from every Air Force installation across the world to use GTO for their programs. Quantitative findings from training questionnaires and ratings of implementation plans as well as qualitative results from resilience personnel interviews suggest some lessons learned for scaling up implementation support. This study builds on established implementation science frameworks for scaling up interventions by identifying critical tasks and unique supports needed to scale up evidence-based prevention. Results suggest GTO helped DAF scale-up prevention across the Department, and that establishing leadership buy-in, simplifying evidence-based program selection and adaptation, monitoring implementation and outcomes, and creating dedicated prevention practitioner roles are critical tasks to support scale-up of evidence-based prevention. Unique supports needed to scale-up evidence-based prevention include multitiered learning systems; integrated tools that improve access to data and evolving evidence; prevention personnel with skills in program management, adaptation, and evaluation; timely crosscutting data; continuous learning to support sustainability; and leadership buy-in.

Equity as a Guiding Principle for the Public Health Data System.

The growing centering of equity in health has elevated a conversation about how those interests should translate within the systems and sectors that influence health. In particular, the public health data system has been relatively limited in capturing the drivers and consequences of health inequity as well as the varying dimensions of equity. This article examines what it means to use equity as a guiding principle throughout the components and functions of a modern public health data system. As with other articles in this supplement, this article builds from a literature review, environmental scan, and deliberations from the National Commission to Transform Public Health Data Systems to summarize current gaps to integrate equity throughout the system. It outlines opportunities for the technology and data science sectors specifically to engage given the access that these sectors have to information that would illuminate and frame the nuances and impacts of health inequity.

What Data Should Be Included in a Modern Public Health Data System.

The public is inundated with data, both in where data are ubiquitously collected and in how organizations are using data to drive public sector and commercial decisions. The public health data system is no exception to this flood of data, both in growing data volume and variety. However, what are collected and analyzed about the health status of the nation, how particular data and measures are prioritized for parsimony, and how those data provide a signal for where to invest to address health inequities are in dire need of a reboot. As with other articles in this supplement, this article builds from a literature review, an environmental scan, and deliberations from the National Commission to Transform Public Health Data Systems. The article summarizes what data should be included and identifies where the technology and data sectors can contribute to fill current gaps to measure equity, positive health, and well-being.

The Issues of Interoperability and Data Connectedness for Public Health.

An unprecedented amount of data is being collected across a diversity of sectors, which, if harnessed, could transform public health decision-making. Yet significant challenges stand in the way of such a vision, including the need to establish standards of data sharing and interoperability, the need for innovation in both methodological approaches and workforce models, and the need for data stewardship and governance models to ensure the protection and integrity of the public health data system. As with other articles in this supplement, this article builds from a literature review, environmental scan, and deliberations from the National Commission to Transform Public Health Data Systems. The article summarizes some of the challenges around data sharing and reuse and identifies where the technology and data sectors can contribute to fill current gaps to promote interoperability and data stewardship.

Technology and Data Implications for the Public Health Workforce.

Achieving a modern equity-oriented public health system requires the development of a public health workforce with the skills and competencies needed to generate findings and integrate knowledge using diverse data. Yet current workforce capabilities and infrastructure are misaligned with what is needed to harness both new and older forms of data and to translate them into information that is equity contextualized. As with other articles in this supplement, this article builds from a literature review, environmental scan, and deliberations from the National Commission to Transform Public Health Data Systems. The article summarizes some of the challenges around current workforce capabilities and pipeline. The article identifies where the technology and data sectors can contribute skills, expertise, and assets in support of innovative workforce models and augment the development of public health workforce competencies.

New prescription fills of selective serotonin reuptake inhibitors before and during the COVID-19 pandemic in Los Angeles County, California.

OBJECTIVE: This study examined whether the COVID-19 pandemic was associated with changes in new selective serotonin reuptake inhibitor (SSRI) prescription fills. METHODS: Using IQVIA Xponent data on new SSRI fills in Los Angeles (L.A.) County from March 2019 to June 2021, the authors implemented an interrupted time series analysis comparing the monthly volume and trend of overall fills and fills by age and gender from before to after the pandemic declaration. RESULTS: The rate of new SSRI prescription fills briefly decreased after the pandemic declaration but then consistently increased through the rest of the study period. These increases were primarily driven by women, young adults (i.e., 18-39 year-olds), and those under 18 years old. LIMITATIONS: Sample is limited to one county and may not be generalizable to other municipalities. CONCLUSIONS: The COVID-19 pandemic was associated with significant increases in new SSRI fills among women, young adults, and those under 18. These increases were relatively small compared to increases in depressive symptoms during the same time period.

Development and pilot test of criteria defining best practices for organizational sexual assault prevention.

Sexual violence affects millions of Americans, and approximately one out of every three women and one out of every four men have experienced sexual violence during their lifetime. While prevention efforts have focused on implementing specific programmatic approaches, there has been relatively little focus on developing comprehensive and effective approaches to reduce sexual assault prevention across an organization. This study describes the development of the Prevention Evaluation Framework, an assessment targeting organizational best practices for comprehensive sexual assault prevention across multiple domains including human resources, collaborative relationships and infrastructure, use of evidence-informed approaches, quality implementation and continuous evaluation of programs/policies. Using the structured RAND/University of California, Los Angeles appropriateness method to develop the assessment, we conducted a literature review and solicited expert feedback about what a comprehensive organizational approach to sexual assault prevention should entail. We then pilot tested the assessment with 3 United States military service academies; and continued to improve and adapt the assessment to a range of organizations with input from 6 Department of Defense headquarters organizations, and 9 universities across the country. Given the nascent state of the evidence about what makes an effective organizational approach to sexual assault prevention, the assessment reflects one way of promoting quality in this evolving field. The consistency between the experts' ratings and the literature, and the relevance of the items across organizations suggest that the assessment provides important guidance to inform the development of comprehensive organizational approaches to sexual assault prevention and to the evaluation of ongoing efforts.

"What We Have Here, Is a Failure to [Replicate]": Ways to Solve a Replication Crisis in Implementation Science.

Adapting the classic line from the 1967 film Cool Hand Luke, the title is meant to convey that implementation science (IS), like other fields, has not been embracing replication studies, which is a key component to the open science movement. The purpose of this article is to review what is known about replication of implementation trials and identify the gaps and next steps to continue increasing the transparency, openness, and replicability of implementation research. After presenting an overview of study replication and how it is a key component of open science, the article will examine how replication of implementation studies has (or more accurately has not) been approached in IS. As will be discussed, replication in IS shares some challenges with studies that attempt to replicate interventions, but also presents unique challenges. This article discusses different types of replications (e.g., direct vs. conceptual) and how they can benefit the field of IS. The article then presents a specific example of an implementation strategy called Getting To Outcomes© to describe how to design a replication study and interpret the results. The article ends with multiple options implementation scientists could consider to improve the likelihood and quality of replication studies. The discussion also envisions how implementation science can enable researchers and practitioners to work together in real-world contexts to encourage wide replication of implementation studies and advance the goal of improving public health.

Cost analysis of a randomized trial of Getting to Outcomes implementation support for a teen pregnancy prevention program offered in Boys and Girls Clubs in Alabama and Georgia.

Implementation support can improve outcomes of evidence-based programs (EBP) for adolescents, but with a cost. To assist in determining whether this cost is worthwhile, this study estimated the cost of adding Getting To Outcomes© (GTO) implementation support to a teen pregnancy and sexually transmitted infection prevention EBP called Making Proud Choices (MPC) in 32 Boys and Girls Clubs (BGCs) in Alabama and Georgia. Enhancing Quality Interventions Promoting Healthy Sexuality (EQUIPS) was a 2-year, cluster-randomized controlled trial comparing MPC with MPC + GTO. We used micro-costing to estimate costs and captured MPC and GTO time from activity logs completed by GTO staff. Key resource use and cost components were compared between the randomized groups, years, and states (to capture different community site circumstances) using 2-sample t tests. There were no significant differences between randomized groups in attendees per site, resource use, or costs for either year. However, there were significant differences between states. Adding GTO to MPC increased the societal costs per attendee from $67 to $144 (2015 US dollars) in Georgia and from $106 to $314 in Alabama. The higher Alabama cost was due to longer travel distances and to more BGC staff time spent on GTO in that state. GTO also improved adherence, classroom delivery, and condom-use intentions more in Alabama youth. Thus, Alabama's GTO-related BGC staff time costs may be better estimates of effective GTO. If teen childbearing costs taxpayers approximately $20,000 per teen birth, adding GTO to MPC would be worthwhile to society if it prevented one more teen birth per 140 attendees than MPC alone.Trial registration. ClinicalTrials.gov , NCT01818791. Registered March 26, 2013, https://clinicaltrials.gov/ct2/show/NCT01818791?term=NCT01818791&draw=2&rank=1.

From Awareness to Action: Accounting for Infrastructure Interdependencies in Disaster Response and Recovery Planning.

This paper highlights challenges and open questions pertaining to physical and social infrastructure system interdependencies and their implications for disaster response, recovery, and resilience planning efforts. We describe the importance of understanding interdependencies in disaster contexts and highlight limitations to existing approaches. Suggestions for understanding and addressing interdependencies focus on increasing availability of tools for assessing interdependencies and increasing stakeholder and decisionmaker uptake of infrastructure interdependency-related information in planning efforts.

Sustaining an Evidence-Based Program Over Time: Moderators of Sustainability and the Role of the Getting to Outcomes® Implementation Support Intervention.

Problematic rates of alcohol, e-cigarette, and other drug use among US adolescents highlight the need for effective implementation of evidence-based programs (EBPs), yet schools and community organizations have great difficulty implementing and sustaining EBPs. Although a growing number of studies show that implementation support interventions can improve EBP implementation, the literature on how to improve sustainability through implementation support is limited. This randomized controlled trial advances the literature by testing the effects of one such implementation intervention-Getting To Outcomes (GTO)-on sustainability of CHOICE, an after-school EBP for preventing substance use among middle-school students. CHOICE implementation was tracked for 2 years after GTO support ended across 29 Boys and Girls Club sites in the greater Los Angeles area. Predictors of sustainability were identified for a set of key tasks targeted by the GTO approach (e.g., goal setting, evaluation, collectively called "GTO performance") and for CHOICE fidelity using a series of path models. One year after GTO support ended, we found no differences between GTO and control sites on CHOICE fidelity. GTO performance was also similar between groups; however, GTO sites were superior in conducting evaluation. Better GTO performance predicted better CHOICE fidelity. Two years after GTO support ended, GTO sites were significantly more likely to sustain CHOICE implementation when compared with control sites. This study suggests that using an implementation support intervention like GTO can help low-resource settings continue to sustain their EBP implementation to help them get the most out of their investment. ClinicalTrials.gov Identifier: NCT02135991.

Short-Term Solutions to a Long-Term Challenge: Rethinking Disaster Recovery Planning to Reduce Vulnerabilities and Inequities.

In the immediate aftermath of disaster, governments usually act quickly to reduce risk and to recover their communities' socio-economic functioning. Policy makers in these situations need-but may not have the capacity or time for-substantial analysis and public debate about how to balance short- and long-term societal needs. Inadequate attention to this challenge may result in a deepening of the inequities that increase vulnerability to disaster impacts. We review case examples to illustrate how post-disaster policies may influence the nature, pace, and inclusiveness of community recovery. We then apply a vulnerability/inequity framework to conceptualize how to enhance disaster recovery and avoid perpetuating inequities when weighing the diverse needs of communities across long time horizons.

Cost Analysis of a Randomized Trial of Getting to Outcomes Implementation Support of CHOICE in Boys and Girls Clubs in Southern California.

Costs of supporting prevention program implementation are not well known. This study estimates the societal costs of implementing CHOICE, a voluntary after-school alcohol and other drug prevention program for adolescents, in Boys and Girls Clubs (BGCs) across Southern California with and without an implementation support system called Getting To Outcomes© (GTO). This article uses micro-costing methods to estimate the cost of the CHOICE program and GTO support. Labor and expense data were obtained from logs kept by the BGC staff and by the GTO technical assistance (TA) staff, and staff time was valued based on Bureau of Labor Statistics estimates. From the societal perspective, the cost of implementing CHOICE at BGCs over the 2-year study period was $27 per attendee when CHOICE was offered by itself (all costs incurred by the BGCs) and $177 per attendee when CHOICE was offered with GTO implementation support ($67 cost to the BGCs; $110 to the entity funding GTO). These results were most sensitive to assumptions as to the number of times CHOICE was offered per year. Adding GTO implementation support to CHOICE increased the cost per attendee by approximately $150. For this additional cost, there was evidence that the CHOICE program was offered with more fidelity and offered more often after the 2-year intervention ended. If the long-term benefits of this better and continued implementation are found to exceed these additional costs, GTO could be an attractive structure to support evidence-based substance misuse prevention programs. Trial Registration. This project is registered at ClinicalTrials.gov with number NCT02135991 (URL: https://clinicaltrials.gov/show/NCT02135991). The trial was registered May 12, 2014.

Influence of an Implementation Support Intervention on Barriers and Facilitators to Delivery of a Substance Use Prevention Program.

Implementation support interventions have helped organizations implement programs with quality and obtain intended outcomes. For example, a recent randomized controlled trial called Preparing to Run Effective Programs (PREP) showed that an implementation support intervention called Getting To Outcomes (GTO) improved implementation of an evidence-based substance use prevention program (CHOICE) run in community-based settings. However, more information is needed on how these interventions affect organizational barriers and facilitators of implementation. This paper aims to identify differences in implementation facilitators and barriers in sites conducting a substance use prevention program with and without GTO. PREP is a cluster-randomized controlled trial testing GTO, a two-year implementation support intervention, in Boys & Girls Clubs. The trial compares 15 Boys & Girls Club sites implementing CHOICE (control group), a five-session evidence-based alcohol and drug prevention program, with 14 Boys & Girls Club sites implementing CHOICE supported by GTO (intervention group). All sites received CHOICE training. Intervention sites also received GTO manuals, training, and onsite technical assistance to help practitioners complete implementation best practices specified by GTO (i.e., GTO steps). During the first year, technical assistance providers helped the intervention group adopt, plan, and deliver CHOICE, and then evaluate and make quality improvements to CHOICE implementation using feedback reports summarizing their data. Following the second year of CHOICE and GTO implementation, all sites participated in semi-structured interviews to identify barriers and facilitators to CHOICE implementation using the Consolidated Framework for Implementation Research (CFIR). This paper assesses the extent to which these facilitators and barriers differed between intervention and control group. Intervention sites had significantly higher average ratings than control sites for two constructs from the CFIR process domain: planning and reflecting and evaluating. At the same time, intervention sites had significantly lower ratings on the culture and available resources constructs. Findings suggest that strong planning, evaluation, and reflection-likely improved with GTO support-can facilitate implementation even in the face of perceptions of a less desirable implementation climate. These findings highlight that implementation support, such as GTO, is likely to help low-resourced community-based organizations improve program delivery through a focus on implementation processes. TRIAL REGISTRATION: This project is registered at ClinicalTrials.gov with number NCT02135991 (URL: https://clinicaltrials.gov/show/NCT02135991). The trial was first registered May 12, 2014.