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      Multicultural Adaptation of Mighty Girls for Widespread Dissemination: Pilot Study, App Development and Usability Testing, and Gauging Parent Support With Focus Groups

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          Taking evidence-based interventions to scale is a challenge for prevention science. Mighty Girls is an evidence-based sexual health intervention program that combines classroom sessions with novel, cutting-edge technology (digital puppetry). The program was developed for 7th grade Latinas, but US school and community demographics rarely allow interventions targeting a single ethnic group. Additionally, digital puppetry is costly to scale up, and parent disapproval often prevents successful dissemination of adolescent sexual health programs. Intervening steps along the scaling-up pathway are needed to adapt the program prior to scaling up for dissemination.


          The aims of this study were to create a multicultural adaptation of the Mighty Girls program using a mobile app that is less costly to disseminate and is acceptable to parents of 7th grade girls.


          This study used a three-phase process to adapt Mighty Girls into Mighty Teens. All phases used purposive (nonprobability) sampling of low-income, multicultural, urban metropolitan groups (7th grade girls and their parents) within central Florida. Phase 1 involved two videotaped implementations of a multicultural adaptation of the classroom sessions, one involving focus groups (N=14) and the other serving as a single-group pretest-posttest pilot study (N=23). Phase 2 involved development of a narrative cell phone app prototype, which was subjected to usability testing (N=25). App usability and engagement were assessed qualitatively (observation, focus group, open-ended questions) and quantitatively. Phase 3 used focus groups to assess parent support for the program (N=6). Qualitative data were analyzed using descriptive content analysis. Quantitative data were analyzed using descriptive statistics and paired t tests.


          Qualitative findings supported classroom sessions being multicultural, and identified simple changes to improve engagement and learning. Quantitative findings from the second classroom session implementation pilot study indicated a significant pre-post difference in intention to delay sexual intercourse ( P=.04). App usability and appeal were supported by a System Usability Scale score of 76 (exceeding 68 per the industry standard) and 83% (20/24) of participants agreeing they would recommend the app to friends. Parents (mothers) expressed only positive regard for program goals, and classroom session and app activities.


          This study adapted Mighty Girls into an engaging, easier-to-disseminate, multicultural program, termed Mighty Teens, that uses a narrative-generating app to support behavior change, and is likely to be accepted by parents of 7th grade girls. This study also provides evidence of the preliminary effectiveness of Mighty Teens classroom sessions. The sampling method and sample size were appropriate for adaptation, but research involving a more representative US sample is needed to confirm multicultural fit, parent receptivity, and program effectiveness. Study implications include integrating app use throughout the classroom sessions to build narrative-generating skills across the program and increasing the number of narratives produced, which should in turn increase the program’s behavior change potency.

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          Most cited references 38

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          An Empirical Evaluation of the System Usability Scale

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            Methodological challenges in qualitative content analysis: A discussion paper.

            This discussion paper is aimed to map content analysis in the qualitative paradigm and explore common methodological challenges. We discuss phenomenological descriptions of manifest content and hermeneutical interpretations of latent content. We demonstrate inductive, deductive, and abductive approaches to qualitative content analysis, and elaborate on the level of abstraction and degree of interpretation used in constructing categories, descriptive themes, and themes of meaning. With increased abstraction and interpretation comes an increased challenge to demonstrate the credibility and authenticity of the analysis. A key issue is to show the logic in how categories and themes are abstracted, interpreted, and connected to the aim and to each other. Qualitative content analysis is an autonomous method and can be used at varying levels of abstraction and interpretation.
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              Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

              Background Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level. Objective Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program. Methods The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback. Results The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs. Conclusions Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

                Author and article information

                JMIR Form Res
                JMIR Form Res
                JMIR Formative Research
                JMIR Publications (Toronto, Canada )
                June 2021
                2 June 2021
                : 5
                : 6
                [1 ] REAL Prevention, LLC Oviedo, FL United States
                [2 ] School of Nursing and Health Studies University of Miami Coral Gables, FL United States
                [3 ] REAL Prevention, LLC Clifton, NJ United States
                [4 ] Department of Communication Arts and Science Penn State University State College, PA United States
                Author notes
                Corresponding Author: Anne E Norris anne@ 123456real-prevention.com
                ©Anne E Norris, Roxana Delcampo Thalasinos, Michael L Hecht. Originally published in JMIR Formative Research (https://formative.jmir.org), 02.06.2021.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

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