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The purpose of this paper is to present a strategy for estimating an individual’s risk of alcohol, cigarette and cannabis use that relies on an assessment of an adolescent’s age, gender and attitude.

The authors assembled surveys from 35,987 11-17 year-olds from 36 databases to examine the relationship between attitude and behaviour.

Attitudes were strongly correlated with concurrent use of alcohol, drunkenness, smoking and cannabis, with correlations of −0.555, −0.517, −0.552 and −0.476, respectively. Logistic regression provided a means for using age, gender and attitudes to estimate an individual’s risk of engaging in substance use behaviour. Developmental changes in attitudes were estimated by analysing changes in scores associated with percentile rankings for each age and gender group. Projected year-to-year changes in attitude were used as a heuristic for estimating future risk.

Analyses relied on cross-sectional panel data. Analyses would benefit from longitudinal data in which age-related changes in attitudes could be more precisely modelled.

Information about estimated current and future risk may prove useful for motivating the adoption and implementation of effective prevention approaches by parents and care providers.

The authors present a novel method for estimating an individual’s risk of substance use knowing attitude, age and gender.

Alcohol, tobacco, marijuana and other drugs use typically increases in prevalence and frequency during middle and late adolescence. School health instruction often focusses on providing facts and rarely provides tools for addressing the psychosocial risk factors needed to prevent substance use. The purpose of this paper is to report about the effectiveness of a prevention programme delivered in US high school health classes. The intervention augments typical instruction by providing teachers with activities that can be infused in their daily teaching.

In total, 26 schools were randomly assigned to receive the intervention or serve as controls. Pupils were pretested near the beginning of the school year, posttest near the end of the school year and administered a final test near the beginning of the following school year. Teachers in treatment schools were provided with activities designed to target psychosocial variables known to mediate substance use onset and self-initiated cessation. These include normative beliefs, intentionality, lifestyle incongruence, beliefs about consequences of use, peer pressure resistance skills, decision-making skills, goal setting skills and stress management skills.

Hierarchical modelling analytic strategies revealed the intervention to have definable positive impacts on alcohol and cigarette use. Moreover, the intervention had strongest effects on alcohol and cigarette use among pupils who were identified at pretest as being lower-than-average risk.

This research provides support for providing teachers with a strategy for preventing alcohol, tobacco and other drugs that can be used in a flexible manner to augment the instruction they are already mandated to provide.

To be effective, evidence‐based programs should be delivered as prescribed. This suggests that adaptations that deviate from intervention goals may limit a program's effectiveness. This study aims to examine the impact that number and quality of adaptations have on substance use outcomes.

The authors examined 306 video recordings of teachers delivering “All Stars”, a middle school drug prevention program. Multiple observers coded each recording, noting the number and type of adaptation each teacher made. Each adaptation was given a valence rating. Adaptations that were deleterious to program goals received negative valence ratings; positive ratings were given for adaptations that were likely to facilitate achievement of program goals; neutral ratings were given to adaptations that were expected to have neither a positive nor negative impact on program goals.

All teachers made adaptations. Teachers were consistent across time in the types of adaptations they made, suggesting each teacher has a personalized style of adapting. Those who made few adaptations, and whose average adaptation was rated as being positive had a higher percentage of students who remained non‐drug users. In contrast, teachers who made many adaptations, whether their average valence rating was positive, neutral or negative, failed to have as many students remain non‐drug users. Measures of fidelity, including quality of delivery and teacher understanding, were related to valence of adaptations, with better performance related to making positive adaptations.

Through training and supervision, teachers should be guided and encouraged to follow programs directions, making few adaptations and ensuring that adaptations that are made advance the goals of intervention. Programs should define acceptable and unacceptable ways they may be adapted.

This study provides significant evidence about the challenges that face disseminated evidence‐based programs.

The editorial aims to provide a brief overview of the individual contributions to this special issue, and a commentary on the contributions in terms of their contribution to the broader issue relating fidelity and adaptation to health promotion research, policy and practice.

This is the first special issue with a focus on fidelity and adaptation. Researchers who have recently examined these issues were invited to submit papers that described recent findings to this special issue of Health Education. Following the traditional double blinded peer review process, five submissions were accepted for publication.

The papers in this issue contribute each in their distinctive way to advancing our understanding of the relative influence that fidelity and adaptation have on moderating outcomes of health education programmes. Fidelity and adaptation must be thought of as independent constructs, each of which influences the outcomes of interventions delivered in school and community settings.

This compilation of papers is the first to systematically address both fidelity and adaptation. Practitioners and researchers alike will gain increased understanding of the potential for fidelity and adaptation to affect outcomes.

All Stars Core is a school‐based drug abuse prevention program for 11 to 14 year olds from the United States. It focuses on five qualities that protect children from drug use: viewing drug use as uncommon and unacceptable to the peer group (norms); viewing drug use as interfering with future goals; commitment to avoid drug use; positive attention from parents; and feeling accepted at school. All Star Plus was recently developed with the goal of expanding the Core program to include the development of three competencies: goal setting, decision making, and skills to resist peer pressure resistance. Students either received All Stars Core, All Stars Plus, or were assigned to the non‐treated control group. Both programs outperformed the control group; however, All Stars Plus was more effective in preventing drug use than All Stars Core. All Stars Plus was found to reduce alcohol use, drunkenness, cigarette smoking, marijuana use, and inhalant use. The Plus program appeared to have achieved these outcomes by improving norms, increasing persistence in pursuing goals, and by increasing attention from parents.

The purpose of this paper is to demonstrate the importance of considering both fidelity and adaptation in assessing the implementation of evidence‐based programs.

The current study employs a multi‐method strategy to understand two dimensions of implementation (fidelity and adaptation) in the Strong African American Families (SAAF) program. Data were video recordings of program delivery and pre‐test and post‐test interviews from the efficacy trial. Multilevel regression in Mplus was used to assess the impact of fidelity to the manual, coded by independent observers, on racial socialization outcomes. One activity on racial socialization, a core component of the program, was selected for an in‐depth examination using conversation analysis (a qualitative method of analyzing talk in interactions).

Results of the quantitative analyses demonstrated that fidelity of the selected activity was associated with increases in parent's use of racial socialization from pre‐test to post‐test, but only when participant attendance was included in the model. Results of the qualitative analyses demonstrated that facilitators were making adaptations to the session and that these adaptations appeared to be in line with cultural competence.

The development of quantitative fidelity measures can be problematic, with many decision points to consider. The current study contributes to the evidence base to develop a quantitative measure of adaptation for family‐based parenting programs.

Many researchers examining implementation of evidence‐based programs consider fidelity and adaptation to be polar ends of a single spectrum. This paper provides evidence for the importance of examining each independently.

The purpose of this paper is to describe the topics covered by coaches assisting teachers implementing a research‐based drug prevention program and explore how coaching affects student outcomes.

The All Stars drug prevention curriculum is implemented by 16 urban teachers who received four coaching sessions. Two coaches participated. Coaches are interviewed by investigators to assess topics covered. Students completed pre‐test‐post‐test measures of mediators and substance use behaviours.

The average teacher is coached on 11.7 different topics, out of a total of 23 topics. Coaching topics most heavily emphasized include: introduction and wrap up; time management; general classroom management; teacher's movement around the class; asking open‐ended questions; using students' questions, comments and examples to make desired points; general preparation; engaging high‐risk youth; reading from the curriculum; implementing activities correctly; focusing on objectives and goals; maintaining a focus on the task; and improving depth of understanding. Seven coaching topics are found to relate to changes in student mediators and behaviour.

The current study is exploratory. Future research should explore how teachers develop the particular skills required by prevention programs and how coaches can assist them.

Five levels of skill development are postulated, which coaches may address: fundamental teaching skills, mechanics of program delivery, development of an interactive teaching style, effective response to student input, and effective tailoring and adaptation.

The paper is one of a very few studies that explores how coaching impacts outcomes in substance abuse prevention.

Most studies of adherence use a single global measure to examine the relation of adherence to outcomes. These studies inform us about effects of overall implementation but not about importance of specific program elements. Previous research on the Strengthening Families Program 10‐14 has shown that outcomes were unrelated to global adherence. The purpose of the present study was to determine whether adherence to specific components of SFP was related to outcomes, even though global adherence was not.

The authors micro‐coded data from an observational study of 11 instances of SFP (N=47 facilitators, 151 participants) into specific process and content components. Using multilevel analysis, they examined the relation of each component to program outcomes, accounting for individual‐ and program‐level variables.

Most associations of adherence with outcome were negligible for European‐Americans but significant for minority participants.

Global assessments of implementation are insufficient for complex, multi‐component prevention programs and may obscure relations of implementation to outcomes. Additionally, program components may function differently based on participant characteristics.

Facilitators would benefit from understanding the function of individual program components, particularly when programs are delivered to diverse audiences. Program developers should provide detailed logic models of program theory to guide facilitators’ decisions about adaptation.

This is one of only a few studies to examine the relation of adherence to specific intervention components to outcomes in a real‐world setting. Results show the utility of component analysis and the importance of considering individual characteristics for implementation assessment.

The current study aims to examine the influence of contextual and provider‐level factors on the implementation fidelity of a research‐based substance abuse prevention program. Also, it aims to investigate whether two provider‐level factors, self‐efficacy and beliefs about the value of the program, statistically moderate and mediate the effects of a provider training intervention on implementation fidelity.

Using generalized mixed‐linear modeling, the authors examine relationships between program provider‐, organizational, and community‐level factors and implementation fidelity in a sample of 50 high school teachers from 43 high schools in eight states across the USA. Fidelity of implementation was assessed utilizing an observation procedure.

Implementation fidelity was negatively associated with the urbanicity of the community and the level of teachers’ beliefs about the value of the program, and positively predicted by the organizational capacity of the school. Comprehensive training significantly increased teachers’ self‐efficacy, which resulted in an increase in implementation fidelity.

School‐based prevention program implementation is influenced by a variety of contextual factors occurring at multiple ecological levels. Future effectiveness and dissemination studies need to account for the complex nature of schools in analyses of implementation fidelity and outcomes.

The authors’ findings suggest that both provider‐ and organizational‐level are influential in promoting implementation fidelity. Before implementation begins, as well as throughout the implementation process, training and ongoing technical assistance should be conducted to increase teachers’ skills, self‐efficacy, and comfort with prevention curricula.

The present study is one of the few to examine contextual and provider‐level correlates of implementation fidelity and use mediation analyses to explore whether provider‐level factors mediate the effects of a provider training intervention on implementation fidelity.

As interventions are disseminated widely, issues of fidelity and adaptation become increasingly critical to understand. This study aims to describe the types of adaptations made by teachers delivering a school‐based substance use prevention curriculum and their reasons for adapting program content.

To determine the degree to which implementers adhere to a prevention curriculum, naturally adapt the curriculum, and the reasons implementers give for making adaptations, the study examined lesson adaptations made by the 31 teachers who implemented the keepin’ it REAL drug prevention curriculum in 7th grade classrooms (n=25 schools). Data were collected from teacher self‐reports after each lesson and observer coding of videotaped lessons. From the total sample, 276 lesson videos were randomly selected for observational analysis.

Teachers self‐reported adapting more than 68 percent of prevention lessons, while independent observers reported more than 97 percent of the observed lessons were adapted in some way. Types of adaptations included: altering the delivery of the lesson by revising the delivery timetable or delivery context; changing content of the lesson by removing, partially covering, revising, or adding content; and altering the designated format of the lesson (such as assigning small group activities to students as individual work). Reasons for adaptation included responding to constraints (time, institutional, personal, and technical), and responding to student needs (students’ abilities to process curriculum content, to enhance student engagement with material).

The study sample was limited to rural schools in the US mid‐Atlantic; however, the results suggest that if programs are to be effectively implemented, program developers need a better understanding of the types of adaptations and reasons implementers provide for adapting curricula.

These descriptive data suggest that prevention curricula be developed in shorter teaching modules, developers reconsider the usefulness of homework, and implementer training and ongoing support might benefit from more attention to different implementation styles.

With nearly half of US public schools implementing some form of evidence‐based substance use prevention program, issues of implementation fidelity and adaptation have become paramount in the field of prevention. The findings from this study reveal the complexity of the types of adaptations teachers make naturally in the classroom to evidence‐based curricula and provide reasons for these adaptations. This information should prove useful for prevention researchers, program developers, and health educators alike.