Teachers' modifications of an evidenced-based HIV prevention program and student outcomes: Findings from a nationwide dissemination

Background: Evidence-based interventions are frequently modified during the implementation process. The degree to which program outcomes are affected by modifications is a significant concern. The national implementation of an evidence-based HIV prevention program targeting grade six students in The Bahamas [Focus on Youth in The Caribbean (FOYC)] offers an opportunity to explore factors associated with teachers’ modification of FOYC lessons.

Methods: Data were collected in the final wave of national implementation conducted in 2012, involving 155 teachers and 3646 students in 77 government elementary schools. Mixed-effects modeling analysis was used to examine the association of teachers’ types and degrees of modification with student outcomes. 

Results: Over one half (54.2%) of the teachers made modifications to FOYC core activities; One-fourth of the teachers modified 25% or more core activities. A high degree of modifications to FOYC curriculum (1/4 core activities) caused diminished program effectiveness. Omitting core activities is the most commonly identified content modification, followed by lengthening FOYC lessons with reading, writing assignments or role-play games, shortening core activities. Omitting core activities has negative impacts on all four student outcomes.  Shorteningcore activities has negative impacts on HIV/AIDS knowledge and/or protective intention.

Conclusions: Teachers who heavily modify the FOYC curriculum demonstrated low levels of implementation and poor student outcomes compared those who make few or no changes to the FOYC curriculum. More intensive pre-intervention training and technical assistance should be provided to the teachers who express low levels of comfort in teaching the intervention curriculum to ensure high quality of implementation.