Implementation and Adaptation of a Multi-Tier Intervention for Immigrant and Refugee Youth: A Process Overview and Evaluation

Background and Purpose. Refugee and immigrant children in the United States often experience traumatic stress yet rarely receive services due to systemic barriers. There is a critical need to systematically evaluate intervention adaptation and delivery to implement and sustain complex multi-tiered interventions in urban contexts to support immigrant/refugee children. However, there is little consensus in the field regarding documentation of intervention modifications, making it difficult to identify mechanisms steering successful/unsuccessful implementation. This presentation will describe a process overview of how the Collaborative for Immigrant and Refugee Children’s Leadership and Excellence (CIRCLE) Project, a partnership between the University of Minnesota and three local community-based agencies serving immigrants and refugees, applied frameworks from community-based participatory research, implementation science, and cultural adaptation to drive community-building, cultural responsiveness, and adoption and sustainability of a trauma-informed evidence-based multi-tiered model–Trauma Systems Therapy for Refugees (TST-R). We will also share findings from TST-R’s first year implementation evaluation, which sought diverse stakeholder perspectives on barriers and facilitators of program adoption and implementation readiness.

Methods. The research team integrated implementation science and community-based participatory methods to adapt and deliver TST-R while balancing fidelity with the local environments’ perceived suitability, sustainability, and alignment with stakeholders’ values and priorities. First, we used the Framework for Reporting Adaptations and Modifications to Evidence-based programs (FRAME) and the Ecological Validity Model (EVM) to systematically document and inform the adaptation of TST-R in Minneapolis. Second, we conducted a qualitative implementation-focused evaluation to understand the perspectives on adoption and implementation readiness of multiple stakeholders working across child- and family-serving systems (clinicians, cultural brokers, parent advocates, and organization leaders). Semi-structured interviews were completed with nine stakeholders in the project’s first year. Interviews were video recorded via Zoom. Analytic memos were completed by research staff following each interview. Data analysis includes iterative coding by multiple researchers and peer debriefing data sessions to inductively identify themes.

Results. The CIRCLE Project is in the process of implementing TST-R in Minneapolis Public Schools. Applying FRAME and EVM to document contextual and cultural modifications allowed the CIRCLE project to explore whether, how, and why intervention modifications were effective/ineffective in diverse schools. Additionally, four cross-cutting themes emerged from the stakeholder interviews: 1) enthusiasm about TST-R for diverse students; 2) the helpfulness of clear communication in consultations, role clarity, and implementation; 3) the importance of cultural brokers and program facilitators with previous TST-R experience; and 4) the role of strong relationships to enhance the model’s adaptability.

Conclusions and Implications. This is the first implementation study to utilize the FRAME and EVM to adapt and deliver a multi-tiered intervention in an urban setting. Lessons learned from the project’s first year will inform future service delivery. This intentional process of adapting and continually evaluating the rollout of TST-R was undertaken to improve services and outcomes for youth and families in the CIRCLE Project. Moreover, the adaptation process and findings from the implementation stakeholder interviews may also be applicable to other multi-agency community-based projects.