Résumé

Cette étude examine le positionnement initial d’intervenants vis-à-vis de l’adoption d’un programme à données probantes (PDP) de soutien à la parentalité, ainsi que les associations entre ce positionnement et l’utilisation du programme pendant les deux premières années de mise en œuvre. Quatre-vingt douze intervenants provenant de 21 organisations participent à l’étude. Des analyses de profils latents permettent d’identifier deux profils se distinguant selon divers aspects de positionnement initial : le Profil 1 (20,7%; n = 19) est nommé “Sceptiques” et le Profil 2 (79,3%; n = 73) est nommé “Optimistes”. L’utilisation du programme ne diffère pas significativement selon le profil. Les résultats soulignent l’importance des facteurs individuels et contextuels dans l’adoption individuelle des PDP. Ils suggèrent que ce qui importe lors du processus d’implantation n’est pas de sélectionner des intervenants optimistes, mais d’offrir aux intervenants impliqués le support requis afin de réduire le plus possible les barrières organisationnelles à l’implantation.

1.2 Abstract

This study is part of a two-year demonstration project to implement an evidence-based parenting program called Triple P. It examines service providers’ initial stance toward the adoption of Triple P. It also examines the association between initial stance and subsequent program use, using three self-reported indicators: whether or not the provider used the program at least once during the two-year demonstration project, the number of families reached during those two years, and the number of Triple P sessions conducted during the last 6 months. Ninty-two providers from 21 organizations participated in the study and received Triple P training during the fall of 2014. Using latent profile analysis, profiles of providers were identified based on their pre-implementation attitudes toward EBPs, self-efficacy, perception of their training needs related to working with parents, perception of the adequacy of their organization’s offices and physical space available to support the implementation of Triple P, and perception of the facilitators and barriers to its implementation (related to the characteristics of the agency, the staff, and the team leader). A two-profile solution was chosen as the best representation of the data. Based on the features differentiating the two profiles, Profile 1 (20.7%, n = 19) was labeled “Skeptics” and Profile 2 (79.3%, n = 73) was labeled “Optimists”. The three indicators of program use did not significantly differ between the two profiles. The results highlighted the importance of both individual and contextual factors influencing individual adoption of EBPs, and informed on the profiles of providers that

should be expected when implementing a new program in a natural setting. They suggest that what matters is not to target only optimistic providers to receive training, but rather provide all providers with adequate support in order to reduce organizational barriers to implementation.

1.3 Introduction

Evidence-based programs (EBPs) that have demonstrated significant effects in controlled environments often fail to yield expected benefits when implemented in the field (MacMillan et al., 2009; Nelson & Caplan, 2014; Pinquart & Teubert, 2010). While there is a rapidly growing evidence base on the dissemination of health promotion interventions (Atkins, Rusch, Mehta, & Lakind, 2016), only a few empirical studies have assessed the factors associated with the successful transfer of skills from a training environment to clinical practice (Horwitz & Landsverk, 2011; Mildon & Shlonsky, 2011). Recent research informed by the diffusion of innovations model (Rogers, 2003), social cognitive theory (Bandura, 1986, 1989) and theories of organizational change (Butterfoss, Kegler, & Francisco, 2008) suggest that the quality of an EBP implementation is influenced by many factors at the individual and contextual levels. However, the impact of these factors on the adoption and use of EBPs by service providers remains unclear.

The present study examines service providers’ initial stance toward the adoption of Triple P – Positive Parenting Program (Sanders, 1999). It also tests the association betweeninitial stance and subsequent usage. Given that Triple P had never before been implemented in the province of Quebec and was either unknown or barely known by the service providers and team leaders involved in this project, it met the criteria of an innovation (Rogers, 1995).

1.3.1 Innovation adoption

In agreement with Aarons, Hurlburt and Horwitz’s (2011) model of implementation, this study focuses on the second and third stages of the process of implementing innovations, that are, the adoption (or pre- implementation) and active implementation phases (following the exploration phase). Innovation adoption refers to the decision by any individual or organization to make use of an innovation (Rogers, 1995). It is the process through which an individual or organization moves from first knowledge of an innovation, to forming an attitude toward it, deciding whether to adopt or reject it, and finally, implementing it (Klein & Knight, 2005; Rogers, 1995). In other words, deciding to adopt an innovation occurs prior to, but is different from, putting it to regular use.

In organizational contexts, Frambach and Schillewaert (2002)’s framework suggests that the adoption decision occurs at two levels: the organizational level and the level of the individual adopter within an organization. The decision of whether to adopt the innovation can either be made by an individual freely and implemented voluntarily, or be made by the organization and implemented enforcedly, which some authors refer to as “forced” adoption (Ram & Jung, 1991) or “authority innovation-decisions” (Rogers, 2003). More specifically, Rogers defined authority innovation-decisions as choices to adopt or reject an innovation that are made by a relatively few individuals in a system who possess power, status, or technical expertise. They differ from “optional innovation-decisions” that are made by an individual independent of the decision of the other members of the system and “collective innovation-decisions” that are made by consensus among the members of a system. According to Rogers, an individual member of the system has little or no influence in the authority innovation-decision; he or she simply implements the decision once it is made by an authority. However, many authors suggest that individuals can resist the innovation (Aarons et al., 2004, 2011; Garland et al., 2003; Glisson, 2002). Aarons (2004) indicate that there is variability in the degree to which providers adopt and comply with new practices even when required by the organization. Hence, an organization can decide to adopt an innovation, but if there is no acceptance among service providers within this organization, it is believed that the innovation may not be used or complied with and the desired outcomes may not be obtained during the active implementation phase. However, very few empirical studies have tested this hypothesis. Little is known about the individual adoption of an innovation within an organization that has already decided to adopt it, as well as the associations with subsequent use of the innovation during the active implementation phase.

Rogers (1995, 2003) produced a widely used theoretical framework on the adoption of innovations among individuals (see Figure 1). He suggested that adopters can be classified into five categories: innovators, early adopters, early majority, late majority, and laggards. Each category reflects “the degree to which an individual is relatively earlier in adopting new ideas than other members of a system” (Rogers, 2003). Innovators are willing to take risks, have access to considerable resources and have a desire to try new things. Early adopters are selective, making judicious decisions regarding the innovations they will adopt and use. They are often opinion leaders, and serve as role models for many other members of the social system. Those in the early

majority are willing to try innovations after a varying degree of time that is significantly longer than that taken

by innovators and early adopters. Those in the late majority approach innovations with a high degree of skepticism, adopting them later than the average participant. Finally, laggards tend to be focused on "traditions," are less likely to take risks, and typically have an aversion to change-agents. Thus, they are the last to adopt, or may even never adopt, innovations. It is important to note that Rogers’ framework assumes that the decision to adopt the innovation is made by an individual freely and implemented voluntarily. Thus, the

validity of these profiles in the context of authority innovation-decisions remains unclear. Exploratory studies are needed to examine if they apply to services providers working within an organisation that has already decided to adopt an innovation.

As asserted by Simpson and Flynn (Simpson & Flynn, 2007), successfully identifying the profiles of adopters could lead to more strategic approaches for improving the effectiveness of the adoption, implementation and dissemination of innovations. However, in previous studies, the categories of adopters have generally been created after the innovation has been adopted. While such post-implementation characterizations may be useful for investigating differences among individuals who adopted the innovation at different times, the ability to identity adopter categories beforehand remains elusive (Smith & Findeis, 2013).

1.3.2 Factors influencing individual innovation adoption

The current literature on the diffusion of innovation and organizational change identify many variables interacting with each other that may influence the individual process of adopting innovations. While the term innovation can apply to a wide range of new ideas or methods, the present study focuses on the factors affecting individual adoption of a new EBP in organizational contexts. These can be grouped in three classes: the characteristics of the providers, the EBP, and the practice context. At each level, there are facilitators and barriers to implementation.

Providers characteristics.

First, Providers characteristics include attitudes towards the innovation, as well as self-efficacy. First, EBPs adoption is a decision-making process shaped by the providers’ attitudes toward the innovation. Aarons (2004) suggests four domains of provider attitudes toward the adoption of EBPs: 1) willingness to adopt EBPs given their intuitive appeal, 2) likelihood of adopting EBPs given requirements to do so, 3) general openness to new practices, and 4) perceived divergence between research- based interventions and current practice, leading providers to be hesitant or skeptical regarding the adoption of new practices. Providers’ attitudes vary according to organizational characteristics and demographic predictors such as organizational climate (Aarons & Sawitzky, 2006), education level, and professional status (Aarons, 2004).

Self-efficacy is also highly relevant for understanding the adoption of EBPs. In the area of interventions, self- efficacy is defined as a provider’s belief in his or her ability to master the specific techniques that are unique to an intervention. Although the results are inconsistent across studies, self-efficacy may be positively associated with a provider’s prior experience with this or similar EBPs, his or her years of experience in the field, and the

extensiveness and quality of the training received (Kavanagh, 1993; Mihalic & Irwin, 2003; Shapiro, Prinz, & Sanders, 2012). Hence, providers who are confident that they have the skills to use a new EBP are more likely to adopt it (Turner & Sanders, 2006).

EBP characteristics.

In terms of EBP characteristics, features that have been shown to enhance innovation adoption are the quality of the program, the amount and quality of training provided, the adaptability and flexibility of the program, the ease with which it can be delivered (i.e., lack of complexity), the observability of its benefits, and its cost-benefit advantages (Damschroder et al., 2009; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). EBPs such as Triple P, whose benefits and cost efficiency have been demonstrated in previous studies, have earned credibility. These programs usually come with the manuals, training and other support required to ensure their implementation with fidelity (e.g., structured protocols). On the other hand, reluctance by providers to follow manuals is often cited as a reason for the lack of adoption of EBPs (Mazzucchelli & Sanders, 2010). However, contrary to what most service providers may believe, flexibility and adaptability are not only allowed, but are actually recommended when using EBPs (Mazzucchelli & Sanders, 2010; Simpson & Flynn, 2007). Thus, service providers should deliver interventions flexibly to meet the diverse needs of the clientele, but in such a way that the intervention is not moved beyond its evidence base (Mazzucchelli & Sanders, 2010). Finally, providers are also more likely to adopt an EBP if they perceive it to be better than the current practice and compatible with their organization’s core beliefs, values, goals and ways of working (Greenhalgh et al., 2004).

Practice context characteristics.

Across multiple studies, the characteristics of the practice context have also been shown to be very important factors in the process of adopting new EBPs (Damschroder et al., 2009; Durlak & DuPre, 2008; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Mendel, Meredith, Schoenbaum, Sherbourne, & Wells, 2008). Providers are more likely to adopt a program if they perceive that their organization has suitable physical environment and adequate and stable financial/human resources to implement it, that team leaders and colleagues support it (Glisson et al., 2008; Sanders & Murphy-Brennan, 2010), that continuous supervision is available, and that the organization has systems and adequate skills to monitor its implementation and evaluate its impacts (Greenhalgh et al., 2004). Turner et al. (2011) found that difficulties integrating a new program into the existing caseload and work responsibilities, as well as poor access to supervision represented the top barriers to program adoption and implementation. ). Neighborhood effect, defined as the community influence on individual, social or economic outcomes, could also apply to implementation factors such as adoption (Bobba & Gignoux, 2014).

In summary, recent studies have brought out a wide range of factors interacting with each other that may impact individual adoption of EBPs in organizational contexts. However, despite the central role that providers play in the implementation process, very few studies have explicitly examined both provider- and organizational-level factors, particularly in the area of parenting programs. While theoretical literature distinguishes between different profiles of adopters, current studies have only examined the factors associated with individual adoption using variable-centered approaches, paying very little attention to individual differences in the patterns of associations among the variables. Thus, it remains unclear how these factors combine to create profiles of individual adopters within organizational contexts. Similarly, despite much research on organizational adoption of innovation, little is known about the individual adoption of an EBP in the context of authority innovation-decisions. Further research is needed to better understanding the profiles of adopters among services providers working within an organization that has already decided to adopt an innovation. Also, although theoretical models and frameworks often link individual innovation adoption and subsequent utilization during the active implementation phase (Aarons et al., 2011; Frambach & Schillewaert, 2002; Klein & Knight, 2005), it remains unclear if providers’ initial stance toward the adoption of an innovation is associated with subsequent program use (e.g., Sanders, Prinz, & Shapiro, 2009; Seng, Prinz, & Sanders, 2006; Shapiro et al., 2012; Turner et al., 2011), especially in the context of authority innovation-decision. The current literature raises the question: can individuals resist the innovation, or does an individual member of the system has little or no influence; meaning that he or she simply implements the decision once it is made by an authority? Because organizational innovations that need to be incorporated in work processes of an organization are of little value if they are not used by providers (Talukder, Harris & Mapunda, 2008), it is essential to determine if individual adoption of an EBP, within an organization that has already decided to adopt it, is associated with program use.

The present study examines service providers’ initial stance toward the adoption of Triple P. It also tests the association between initial stance and subsequent usage. Triple P is designed to promote healthy development among children and improve behavior by modifying the dysfunctional parenting practices, family interpersonal relationships and interaction patterns that contribute to children’s behavior problems. It emphasis on minimal sufficiency and promotion of self-regulation, and aims to increase parental competence and confidence in raising children. More specifically, the program incorporates five intervention levels on a continuum of intensity. The system includes media-based communication strategies (Level 1), educational strategies (Level 2), individualized parental coaching (Level 3), training in parenting skills (Level 4), and more intensive support for parents with complex concerns (Level 5). Triple P has been proven to be effective by randomized controlled trials conducted across various socio-economic groups, with culturally and linguistically diverse parents (Eyberg, Nelson, & Boggs, 2008; Nowak & Heinrichs, 2008). Moreover, meta-analyses report

that Triple P has shown positive effects on various parenting and child outcomes including parents’ wellbeing, parenting skills, parental stress, children’s behavioural and emotional problems, and parent-child relationship (De Graaf, Speetjens, & Tavecchio, 2008; Nowak & Heinrichs, 2008; Sanders, Kirby, Tellegen, & Day, 2014; Thomas & Zimmer-Gembeck, 2007).

Recent studies have examined providers’ use of Triple P through surveys (Turner, Nicholson, & Sanders, 2011) or interviews (Sanders et al., 2009; Seng et al., 2006; Shapiro et al., 2012) conducted among services providers, six months (Sanders et al., 2009; Seng et al., 2006; Turner et al., 2011) or two years (Shapiro et al., 2012) after their initial training. These studies assessed usage by asking providers whether or not they had used Triple P at any time since their initial training (Sanders et al., 2009; Seng et al., 2006; Shapiro et al., 2012), or the number of families with which they had used it (Shapiro et al., 2012; Turner et al., 2011). Thus, most authors have conceptualized usage as a dichotomous variable. However, it is critical to determine whether, in addition to merely providing an EBP, service providers are doing so to a reasonable extent (Shapiro et al., 2012). Although several authors have pointed to the need to measure multiple aspects of EBP delivery in order to achieve a comprehensive picture of implementation processes (Hasson, 2010), in studies examining usage as a continuous variable, this variable has generally been assessed using only one indicator.

1.3.3 Current study

The present study examines service providers’ initial stance toward the adoption of Triple P, an EBP implemented for the first time in the province of Quebec, Canada. It also tests the association between initial stance and subsequent program use during the first two years of active implementation. Using latent profile analysis (LPA), a person-centered analytic approach, we sought to identify profiles of providers based on a variety of indicators of their initial stance toward the adoption of Triple P: their attitudes toward EBPs, their self- efficacy – or confidence – in conducting consultations with parents about child behavior, their perception of their training needs related to working with parents, their perception of the adequacy of their organization’s offices and physical space available to support the implementation of Triple P, and their perception of the facilitators and barriers to its implementation (related to the characteristics of the agency, the staff, and the team leader). The aims of this study were to: 1) identify naturally occurring initial stance profiles among the providers, 2) examine how these profiles differ and if they are consistent with Rogers’ theoretical framework on the adoption of innovations among individuals, and 3) examine the association between these profiles and three self-reported indicators of program use: whether or not the provider used the program at least once during the two-year demonstration project, the number of families reached during those two years, and the number of Triple P sessions conducted during the last 6 months. In light of the literature consulted, it is

expected that, based on underlying latent variables, providers will be divided into distinct profiles reflecting different categories of adopters. Given the exploratory nature of the second objective, there is no formal hypothesis regarding the similarities or dissimilarities between the expected profiles and Rogers’ theoretical framework. However, it is expected that the profile-s caracterized by a higher willingness to adopt Triple P will be associated with a higher probability of usage and a higher amount of usage (indicated by the number of families reached and the number of sessions conducted) during the two-year demonstration project.

1.4 Method

This study grew out of an initiative to implement Triple P in two health care catchment areas (Community 1

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