A Coach-Delivered Dating Violence Prevention Program: Coach Perspectives on Implementation

Abstract

Coaching Boys into Men (CBIM), an evidence-based violence prevention program, utilizes the coach-athlete relationship to deliver information about healthy, respectful relationships to adolescent boys involved in athletics. Although CBIM has demonstrated effectiveness in clinical research trials, its implementation outside of an effectiveness study has not been explored. The purpose of this current study was to explore facilitators and barriers of effective implementation in community settings using experiences from one regional implementation in Southwestern Pennsylvania. Head coaches who implemented CBIM from 2017-2018 seasons (n = 35) were contacted and 22 (63%) agreed to participate. Coaches were asked how they delivered CBIM to their team, what aided the process, barriers to facilitation, and their overall thoughts on CBIM implementation. Interviews were structured to uncover specific information regarding implementation while also providing time and space for coaches to voice their suggestions and opinions. Interviews were coded using descriptive content analysis. Key facilitators to implementation were involvement of violence prevention advocates, athletic directors, assistant coaches, and players and having flexibility to integrate current events to emphasize topics covered in CBIM. Observed improvements in bystander intervention behaviors and better attitudes towards women and girls among athletes were key motivators for coaches to continue the program. Main barriers were inconsistencies in time available to discuss topics with players and need to refresh curriculum content over multiple seasons. Coaches identified components necessary for broader and sustained implementation of this evidence-based violence prevention intervention in community settings. Coaches’ confidence in delivering program content can be bolstered with appropriate strategies in place to address barriers. As coaches witness positive impacts among their athletes, these successes contribute to coaches recognizing their role in transforming sports into a platform for community-wide violence prevention.

Keywords

implementation coaching boys into men athletics coaches

Introduction

Teen dating violence is a prevalent public health issue in the United States, with 26% of women and 15% of men who were victims of intimate partner violence experiencing this for the first time before age 18 (Smith et al., 2018). The CDC defines teen dating violence as a type of intimate partner violence affecting young people that includes such behaviors as physical violence, sexual violence, psychological aggression, and stalking (Niolon et al., 2019). Dating violence during adolescence has been associated with numerous long-term adverse health outcomes including depressive symptoms, suicidal ideation and attempts, tobacco and marijuana use, pregnancy, sexually transmitted infections, and interpersonal violence (IPV) victimization in young adulthood (Ackard et al., 2007; Exner-Cortens et al., 2013; Haynie et al., 2013; Pengpid & Peltzer, 2020; Swahn et al., 2008; Vagi et al., 2013). Use of violence in relationships occurs across multiple settings including among athletes, with violent behavior “off-the-field” considered an “everyday dynamic at the center of male athletic culture” (Messner, 2002).

Since 1989, the number of high school athletes in America has continuously increased with sports being an integral part of U.S. culture among adolescents (National Federation of State High School Associations, 2018). As athletes are often regarded as leaders in their school communities, sports may offer an influential platform for violence prevention (Fraser-Thomas et al., 2005; Jaime et al., 2018; Katz et al., 2011; Miller et al., 2013; Shakib et al., 2011) Participation in sports, however, has also been associated with use of sexual and dating violence, including higher prevalence of sexual violence perpetration among some athletes compared to non-athletes (McCray, 2015; National Federation of State High School Associations, 2018). These factors combine to create a unique opportunity to use sports as a key setting for dating violence prevention programming. Bystander intervention programs are promising avenues to address dating violence, specifically increasing willingness and confidence to intervene with peers engaging in harmful behaviors (Storer et al., 2016).

Coaching Boys into Men (CBIM) is an evidence-based violence prevention program that utilizes the coach-athlete relationship to deliver information about healthy, respectful relationships to high school and middle school male athletes (Miller et al., 2012, 2013, 2020). A coach is considered to be among the most influential adults in an athlete’s life, aside from parents and adult caregivers (Jaime et al., 2018; Raj et al., 2017). Coaches have the ability to empower their athletes, and this impact can be used to guide youth beyond athleticism towards respect and nonviolence (Futures Without, 2018a). A strong coach-athlete relationship is known to influence an athlete’s confidence (Côté & Gilbert, 2009). Coaches have the opportunity to use this influence to teach their athletes skills that can reduce violence perpetration and increase their willingness to intervene with peers’ harmful behaviors. The CBIM program offers coaches tools to harness their influence positively, enhancing the level of impact they can have on their athletes, team, school, and community.

Coaching Boys into Men provides coaches with structured scripts (called the CBIM Card Series or “the cards”) that guides them through discussing 12 topics with their team regarding respect, healthy relationships and consent (Futures Without, 2018b). Once a week for 15 minutes, coaches introduce their team to a topic using a script and guided questions from the card series. The CBIM curriculum and training materials are available for free download, making the program widely accessible. While any coach can access the materials online, the recommendation for this program is for a coach and advocate (or prevention specialist) to work in partnership to implement the program. An advocate is typically located within a local domestic or sexual violence victim service agency. The role of the advocate (or violence prevention specialist) is to serve as the trainer and support system for coaches, introducing coaches to key concepts such as why engaging men is important, how to build CBIM into athletic practice time, and how to facilitate discussions. Advocates attend a 2-day CBIM Training Institute conducted by Futures Without Violence where they learn: the importance of engaging men; the skills to implement CBIM curriculum; how to conduct community readiness assessments; how to gain school administrator, coach, and community buy-in; how to train coaches; how to conduct program evaluation; and how to promote program sustainability in their communities. The advocate then goes on to recruit, train, and support the coach using this training in addition to their background knowledge of dating violence prevention. Advocates also attend supplemental monthly learning collaboratives to enhance their skills on how to support their coaches. Although coaches deliver the program and lead implementation, advocates remain available to give additional support as needed, often through biweekly check-in phone calls with coaches. Should a student athlete disclose abuse or violence to their coach the advocate is available to provide assistance to both the coach and the athlete.

In 2009, the CDC funded a randomized controlled trial (RCT) of CBIM in 16 high schools in Sacramento, CA. Athletes randomized to the intervention arm displayed increased positive bystander intervention and intentions to intervene, and at 12-month follow-up showed decreased physical, sexual, and emotional abuse perpetration when compared to athletes in control schools (Miller et al., 2012, 2013). CBIM has now spread to high school teams across all 50 U.S. states and has been translated and adapted for use internationally. In 2014, the CDC funded an RCT of CBIM in 41 middle schools across the Greater Pittsburgh area. Male athletes receiving the intervention reported increases in positive bystander behaviors (such as intervening when a peer was being disrespectful toward others) by more than 50% by the end of the sports season, and this effect persisted at 1 year of follow-up. Among those athletes who had ever dated (about two thirds of the sample), athletes in schools implementing CBIM had 76% lower odds of abuse against a romantic partner 1 year later (Miller et al., 2020).

Implementation of evidence-based programs such as CBIM is a known challenge in violence prevention. Implementation science is an emerging field focused on investigating this chasm between effectiveness trials and uptake in “real world” settings. A focus on implementation acknowledges contextual barriers and facilitators to program uptake with the goal of easing the process so that evidence-based innovations are actually used and provide the public health benefit they were designed for (Bauer & Kirchner, 2020). Given many theories, frameworks, and models in the field, Durlak and Dupre conducted a scoping review in which they identified 23 factors that most affect implementation, divided into five categories: (1) community level factors (e.g., politics, policy, and funding), (2) provider characteristics (e.g., perceived needs for innovation, its benefits, and proficiency of implementation), (3) characteristics of the innovation (e.g., program compatibility and adaptability), (4) factors relevant to the prevention delivery system (e.g., organization climate, practices, and processes), and 5) factors related to the prevention support system (e.g., training and technical assistance) (Durlak & DuPre, 2008). These categories address the multiple levels that influence implementation, allowing for attention to factors across different levels (e.g., individual, systems), inclusive of stakeholders, administrators, implementers, and the target population (in this case, athletes).

In intent-to-treat analyses, CBIM has been found to increase positive bystander behaviors and reduce the use of sexual and partner violence among both middle and high school male athletes 1 year later (Jaime et al., 2014; 2018; Miller et al., 2013). With intensity-adjusted analyses (i.e., when CBIM is implemented as intended), the intervention effects are even more pronounced (Miller et al., 2013, 2020). While CBIM has demonstrated effectiveness in clinical trials, implementation of this program in real-world settings outside of an effectiveness study has not been explored. In 2012, the United Way of Southwestern Pennsylvania and FISA Foundation came together to support a community-wide dating and sexual violence prevention effort called ‘Southwest PA Says No More’ that brings together individuals and community organizations committed to ending sexual and domestic violence (Southwest PA Says No More, n.d.). CBIM was one of the core strategies for this prevention effort, with an ambitious goal of training 2000 coaches across 16 counties in southwestern Pennsylvania over several years. This current study focused on the cohort of 35 coaches who were trained and delivered CBIM during the 2017-2018 sports season. Local advocates provided a pre-season training session, organized coach networking events, and were available for consultation and assistance throughout the sport season in addition to providing training and check-ins with each coach. Advocates convened small groups of 4–8 coaches to facilitate a one-time 90-minute Coaches’ Leadership Training session introducing coaches to CBIM. During the training session, advocates lead a series of activities to explain the influential role of coaches in their athletes’ development, define abusive and healthy relationship behavior, introduce coaches to CBIM materials, and provide an opportunity for coaches to practice implementing CBIM card series. An ongoing, comprehensive evaluation of CBIM was initiated to examine how this community-wide prevention effort could be disseminated and scaled up to reach a larger number of coaches throughout the region, while tracking the fidelity with which the program itself was delivered. This evaluation provided an opportunity to reach coaches participating in CBIM outside the structure of a research study and to interview and gather data regarding their process of delivering the program to their teams. The purpose of this study was to elucidate coaches’ perspectives on what helped them to implement, and ultimately sustain, the program with their teams. In particular, this study involved a select group of coaches, situated in school settings, who have emerged as champions of the program, many of whom have not only successfully implemented the program but are sustaining the program beyond one sports season. These early adopters of the program may provide critical insights on program implementation, dissemination, and sustainability.

Methods

Procedures

Coaches consented to being contacted by the evaluation team when they first agreed to participate in delivering CBIM as part of the United Way and Southwest PA Says No More effort to disseminate CBIM. Participating in an interview regarding CBIM after their season concluded was entirely voluntary. No incentives were offered to coaches for completing the interview.

The United Way of Southwest Pennsylvania provided funding to the advocates to lead the training and technical assistance for CBIM, including recruitment of coaches. Head coaches whosigned up to implement CBIM in the Winter 2017 through Fall 2018 seasons (n = 35) were contacted via email and telephone requesting a 30–60-minute interview about their experience with the program; 22 (63%) agreed to participate. Coaches were contacted without knowledge of how much of the program they had implemented. Each coach verbally consented to participate in a recorded interview. These coach interviews were conducted within 3 months of the conclusion of their sports season. Interviews were completed by trained research assistants by phone and recorded with permission. Identifying information was removed during transcription.

The interview guide was created using Durlak and Dupre’s (2008) review, with questions corresponding to the factors affecting the implementation process noted above. These factors explore the implementation process at various levels and helped explore each team’s experience utilizing CBIM. These interview questions provided a lens into coach perspectives on what is needed to implement the program, their motivations to participate, and their experiences with implementation (Durlak & DuPre, 2008). Data regarding coaching experience, coaching staff, and team make-up were also collected (Appendix A: Supplemental Table 1). Questions additionally inquired about observed athletes’ behavior noting any potential impacts CBIM had on their athletes to assess how coaches perceived need and effectiveness of the program (Supplemental Appendix B: CBIM Interview Questions for Implementing Coaches). The University of Pittsburgh Institutional Review Board deemed this evaluation as exempt (PRO16010358).

Analysis

Coaches were asked how they delivered CBIM to their team, what aided the process, barriers to facilitation, and their overall thoughts on CBIM implementation. Interviews were structured to uncover specific information regarding implementation while also providing time and space for coaches to voice their suggestions, questions, and opinions. Interviews were conducted by one of four research team members. Two of the interviewers were White women, one was a Black man, and final interviewer was a Latinx man. Interviews were transcribed verbatim by research assistants and uploaded to the Dedoose qualitative analysis software (Version 8.2.14). Descriptive content analysis was used in this study to review interview transcripts to discover patterns, generate themes, and describe coaches’ experiences with implementation (Hsieh & Shannon, 2005). Descriptive content analysis was conducted by two independent coders (one White woman and one Latinx man), with discrepancies resolved using a consensus process to create a codebook with definitions for each of the codes. A priori codes included all five domains of implementation from Durlak and DuPre’s (2008) review. Research team members then systematically analyzed data to identify themes related to coaches’ reported and observed implementation practices using a directed content analysis approach (Hsieh & Shannon, 2005). All transcripts were coded by two research team members using the final codebook. Team members identified systemic, institutional, and interpersonal factors affecting coaches’ implementation practices. Content related to implementation barriers and facilitators as well as coaches’ perspectives on their motivations and perceptions of outcomes were extracted and specific themes and subthemes identified. A third reviewer was available to address coding disagreements, which did not arise.

Results

Twenty-two coaches with an average of 18 years of coaching experience completed an interview. Eight of the coaches were completing the program for a second or third season. The coaches represented 15 different schools and seven different sports, reaching an estimated 630 athletes. The team size ranged from 12–82 athletes (median = 36 athletes) with 5 teams being co-ed. Brief descriptions about the coaches, school districts and teams are summarized in Table 1, along with self-reported data about how many CBIM sessions the coaches estimated completing (Supplemental Appendix A). On average the coaches completed 8 or more of the 12 cards with their teams, and spent an average of 15 minutes per session, with a range of 5–40 minutes. Of the five co-ed teams, three delivered CBIM to only the male athletes, one involved the female athletes “a little bit”, and one attempted to deliver a “girl program” to the female athletes. The results are organized to align with the five implementation categories identified in Durlak and Dupre’s review. We have highlighted the coaches’ perspectives on the role of the advocate; overarching themes of facilitators’ perceived proficiency in implementation, and barriers to implementation as well as coaches’ observations of perceived need and impact of the program.

Facilitators of Program Implementation

The two prominent themes related to facilitating program implementation were having support from multiple other sources (factors related to the prevention support system) and knowing that the program was flexible enough to supplement the cards with current events (characteristics of the innovation).

Factors Related to the Prevention Support System

Support from others was identified by every coach as a critical factor that facilitated program implementation. This support came from multiple sources, including domestic violence advocates, athletic directors, assistant coaches, and the athletes on the team. Coaches felt more comfortable delivering the CBIM program when they felt they had administrative and community support.

Support from local victim service advocates

Coaches repeatedly noted that they appreciated working with their advocate and that continued contact during the program was a key component of their success. Initial contact before the start of the program helped address initial hesitancy about implementing the program. However, it was the contact throughout the season that seemed to make a large difference, with coaches reporting:

“[advocate] is in constant contact with me” and “I probably talk to [advocate] two, three times a week”. - Coach # 1

Coaches discussed support ranging from advocates attending a game,

“He came to… a few of our games. Not even to deliver cards or anything, just to … stay in touch and watch the team play and talk to the kids”. - Coach # 1

being present for a session,

“he came and did the first card actually with the kids”. - Coach # 2

or being available to answer questions by phone or email.

"if there was anything that I needed you know if I had questions about I would just call him right up, he was right there”. - Coach # 20

Coaches who were implementing the program for the first time spoke about the advocate’s instrumental support in showing them how to administer the program. For coaches who had implemented the program previously, the advocate’s role became more peripheral but still present and supportive to promote long term commitment to the program.

Support from athletic directors

Athletic Directors were frequently the main proponents for implementing CBIM across their school district and often introduced the program to coaches.

“Well the fact that our athletic director basically said we were going to do it made it pretty easy to do it. When she said, ‘We are going to be doing this,’ I was like, Alright! So, we’re doing this!” - Coach # 9

Coaches identified the meaningful impact of having CBIM as a priority of their Athletic Director. Coaches appreciated having the Athletic Director check in on the program and show interest in the team’s progress. Coaches also noted that they felt supported through a more hands-off approach, expressing that they felt trusted by the Athletic Directors to complete the program with their team how the coaches themselves deemed best. One coach said,

“They trust our coaches to be professional and deliver this in a respectful manner. And for that obviously, we’re grateful for that”. - Coach # 7

Support from assistant coaches

Although assistant coaches vary in number and role across teams, those coaches with assistant coaches who were involved with CBIM implementation appreciated their involvement. Most head coaches had different methods of including their assistant coaches in CBIM, ranging from dividing the cards amongst coaches,

“No, actually all four of us would, we kind of rotated through [the cards]”. - Coach # 1

to taking the lead but still having other coaches chime in with their own input and experiences.

“It ends up turning into, as it should, a conversation, so it’s nice to have the other coaches there”. - Coach # 3

Head coaches thought having multiple coaches willing to participate reiterated the importance of the program, and that hearing different voices and backgrounds deliver the cards could only help the athletes’ absorption of the information. One coach said:

“I kind of felt like the kids hearing different voices would be different rather than hearing the messages from me all the time. I think, just to get different voices, different adults, different stories, different opinions”. - Coach # 1

Support from athletes

Teams were made up of athletes of multiple ages and experiences allowing certain athletes to serve as leaders in CBIM delivery. Typically, these athlete leaders would begin discussion facilitation by providing their opinions and responding to the days topic.

“one of my captains, and another kid who were really good on like opening up on the first day and really getting discussions. I think that really helped.” - Coach # 6

When older teammates had participated in the program for multiple seasons, taking a leadership role in the delivery added some novelty and reinforced the information through teaching and sharing. One coach noted that,

“I had about a handful of the kids that really embraced it, and they would actually, some of them, they would actually pick the lesson, and, basically [would] lead the discussion.” - Coach # 15

Characteristics of the Innovation

Coaches noted that CBIM was a flexible enough program that they were able to integrate current events surrounding unhealthy relationships, social media use, and sexual harassment within the school, region, or nationally on the news. Relating the cards to real world events increased the relevance of the material to the athletes, while giving coaches a way to explain why they were doing CBIM. Some coaches focused on sexual violence coverage in the media,

“The “Me Too” movement this year was really a big thing that we talked about a lot”. - Coach # 15

while others focused locally.

“One of them brought up a too that was happening in school and they were… able to come up with kind of a plan or a solution or something that they were going to take back to the situation”. - Coach # 10

Coaches took ownership of their program delivery, making connections and finding examples to make the implementation most relevant to themselves and their players. Many coaches felt empowered to change the order of card delivery as topics came up throughout the season.

“Certain things would happen in school…and you just, you kinda think to yourself oh, now would be a good time to talk about this… because they’re at the forefront of everyone’s minds”. - Coach # 1

Other coaches tried to pull together a real-world example for each card to discuss:

“I used the cards for an outline, and try to relate it… to current things or something that maybe I experienced, or something that was going on in the world”. - Coach # 15

If a topic was closely related to something happening in the school, sometimes coaches would bring in the advocate to help facilitate that conversation. Overall, coaches perceived success of effectively communicating the practical implications of CBIM if athletes acknowledged understanding the importance of the topic and found ways to address those topics within their own lives.

Barriers to Program Implementation

Although many coaches delivered at least 8 of the 12 total cards (range 2–12; median 8) over a varying number of sessions indicating overall success with implementing the program, the coaches noted key personal barriers (provider characteristics) which included perception of not having enough time as well as limitations of the prevention delivery system, specifically the repetitiveness of material season to season.

Insufficient time

Program implementation always requires designated time in addition to normal activities which was the main barrier noted. Coaches widely expressed that,

“the only obstacle was actually finding the time to meet”. - Coach # 10

The reasoning varied between school, sport and season, but overall coaches said they would have accomplished more of the program if they had more time.

“I was really glad we did it. I just wish we could’ve got more sessions in.”. - Coach # 6

Weather also significantly impacted program delivery for outdoor sports. The spring of 2018 was particularly rainy in Southwestern Pennsylvania, leading to lots of cancellations and make up games later in the season. Teams that designated times to deliver a CBIM card fell behind from cancelled practices, early dismissals and practice turned game days. One coach stated,

“I’ve been doing this for like around twenty years and this was the worst weather-wise spring that we’ve ever gone through… the way practice was and rescheduling some meets and stuff like that, I wasn’t able to do it every week”. - Coach # 6

This made it difficult for the coaches to best utilize time, but also needed some flexibility as the weekly schedule would change often.

“You’ve gotta be regimented to the fact you’re gonna set that time aside every week”.

- Coach # 18

The cards were designed to be easily integrated into regular coaching activities by summarizing points with the expectation that sessions are 15 minutes or less. Many coaches in our study noted aiming for a more discussion-oriented session, where they provided space for questions, concerns and examples leading which created sessions that ranged from 5 minutes to over an hour. One coach’s solution was to utilize bus rides to deliver cards.

“Well, when you’re playing, when you’re squeezing games in to get rained out, and you’re trying to have all the kids together and you want to get as much of the program in as you can. And a long bus ride provides an opportunity where you have everyone’s attention and everyone’s pretty quiet and you’re able to talk about those things”. - Coach # 7

This recommendation included advice to other coaches to maintain flexibility and creativity with delivery time.

Repetition of the Program Across Multiple Sports and Seasons

In the context of the multi-year, community-wide “Southwest PA Says No More” prevention effort, many coaches interviewed had delivered the CBIM curriculum more than once, which was mentioned as both a facilitator and barrier to success. Some coaches and athletes were more comfortable with CBIM after season one.

“I was a lot more confident than year one … now the players understand the program better, they know we spend a ton of time on character development it’s kind of ingrained in them and obviously you’re more familiar with the content and the message you are trying to deliver”. - Coach # 17

However, a few coaches also had concerns that the material was becoming repetitive over the seasons. Multi-sport athletes could receive the program three times a year, through 4 years of high school, and coaches expressed worries about keeping the information fresh and novel for the athletes.

“I also think if we pounded it every week, every week, every week. It would be like here we go again”. - Coach # 17

Despite this repetitiveness, coaches still wanted to continue implementing the program each season. Coaches reported integrating current events and local school incidents into the curriculum to maintain the novelty of the curriculum and improve their delivery each session.

Observed Impacts with Implementing the Program

In addition to provider (coach) characteristics, characteristics of the program itself, and factors relevant to the prevention delivery system and prevention support system, coaches also highlighted an additional key facilitator which was rapid changes in their team’s behaviors (i.e., community-level change) which in turn strengthened coaches commitment to the program. Coaches shared examples of the positive impacts they observed with the program which contributed to a personal sense of accomplishment– specifically, positive bystander intervention behaviors and other communication they observed among their athletes, all of which contributed to greater motivation for implementing the program.

Positive bystander intervention

While coaches were limited to mainly seeing their athletes interact with each other, coaches felt there was an increase in positive bystander intervention among athletes.

“One of our guys made a comment… and another guy said ‘we just had a card on that yesterday, we just talked about that’ or maybe somebody got mad and said something—not so much derogatory, but inflammatory maybe. And then you’d hear a bunch of kids going ‘Uh-uh! CBIM! Uh-uh! CBIM!’” - Coach # 13

One coach reported receiving compliments from teachers:

“that the way our players, they see a difference in the way our players conduct themselves a little more humility, you know they’re just you know good, good role models in the building”. - Coach # 17

Improved attitudes towards women and girls

Although most coaches felt they could not truly assess changes in player attitudes, coaches of co-ed teams were able to notice better behaviors among their male athletes towards their female teammates.

“I definitely saw a change that way that you know, the girls went from last year almost being outcasts—they were never treated poorly but you could tell that they weren’t readily accepted—to this year they were just teammates on the team”. - Coach # 10

Coaches of all male teams mentioned improved language amongst their athletes when discussing girls.

“And I’ll say that one thing I notice from last year to this year is you don’t hear that vulgar talk about girls. You don’t hear that vulgar speaking about. I think just bringing a program in and talking about these things, and talking about how speaking about your, you know, sexual experiences is not… we don’t want to hear that. And I think that we didn’t hear that stuff this year.” - Coach # 7

Discussion

This is the first study to examine the implementation of this evidence-based violence prevention program outside of an effectiveness study. In these interviews, coaches identified factors that were critical to implementation in communities in Southwestern Pennsylvania. As coaches are the key implementers of this program, elucidating best practices to support implementation from their perspective is essential to scale this highly effective program in community settings. While lack of time and redundancy were personal challenges for some, coaches were able to identify two core areas that facilitated successful implementation: having support from different members of their community (including victim service advocates) and the compatibility/adaptability of the intervention to the organizational practices and community needs. The findings from this study are best understood when contextualized within the five domains of Durlak and Dupre’s (2008) implementation framework.

Factors Related to the Prevention Support System

Training coaches to ensure they possess the skills necessary to deliver program curriculum as well as access to resources for continued skill development and implementer support were highlighted as a key factor of successful implementation for coaches. Coaches are not expected to be experts in the material and the advocate serves as a resource to offer local knowledge and form a partnership with the coaches. Given the importance of coaches’ training, especially on subject matter with which they may be unfamiliar, the one-time 90-minute training session coaches receive from advocates may not be sufficient to support coaches’ successful implementation. Because coaches are not expected to be experts, the advocate-coach relationship becomes increasingly important. In this study, all coaches had an advocate that worked with them consistently throughout the implementation period. The coaches’ emphasis on the role of the advocate in supporting program implementation is consistent with findings from interviews conducted with coaches from a CBIM randomized trial who also highlighted how critical it is to have the advocate available for ongoing technical assistance throughout a sports season (Jaime et al., 2018).

In community-wide implementation, however, without the oversight of a research study, implementation may be less controlled, leaving the possibility of varying levels of advocate support. Any coach can download and deliver CBIM to their team without formal training or a proper introduction to curriculum materials. Increased accessibility to CBIM offers greater dissemination of this programming in communities and, while virtual resources are offered to coaches who decide to deliver CBIM without formal training, this study supports the recommendation by developers of the curriculum to deliver CBIM in partnership with an advocate. The CBIM advocate kit recommends connecting with coaches before each season begins and conducting regular check-ins – including visiting team practices and attending team home games to show support for both the coaches and players (Futures Without Violence, 2018c). United Way of Southwest PA has worked to build teams of coaches and advocates engaged and invested in decreasing sexual violence in their region. Consistent and sustained formal training, community support, and access to resources are integral to coaches’ implementation and should be cultivated whether advocates are recruiting coaches or coaches are initiating the delivery of CBIM.

Factors Relevant to the Prevention Delivery System: Organizational Capacity

Coaches require the support of their athletes, coaching staff, administrators, advocates, and community members to deliver CBIM sustainably. Often when the advocate leads the charge to begin implementing CBIM in a particular institution, they have already garnered community and administrator buy-in. Coaches acting as internal advocates in support of CBIM, with coaching staff, athletes, and their families, serve to increase enthusiastic program participation and sustainability. Coaches reported support from athletic directors, assistant coaches, and athletes not only improved participation in CBIM, but also strengthened their sense of community. Coaches also reported the desire for some level of autonomy from administrator (i.e. athletic directors) when delivering CBIM to their athletes. Coaches preferred a shared decision-making process when bringing programming to their athletes rather than administrative mandates, which can diminish buy-in from coaches and thus negatively impact their implementation. While mandating a program such as CBIM to be delivered by facilitators/coaches does ensure programming will occur, these findings confirm that mandated delivery of programming diminishes both trust and enthusiasm between administrative leadership and coaches as well as coaches’ buy-in to CBIM. As Durlak and Dupre’s review underscores, for innovative programming to be adopted for sustainable delivery community members, coaches, and administrators must all be willing to engage in and support coaches in the delivery of CBIM. That is, community members must know, understand, and agree with the principles of programming and believe that their adolescent community members would benefit from such programming and that they have an obligation to support coaches as implementors. Coaches have relationships with and support from administrators such that they know their organization recognizes their ability to deliver such programming. And, most importantly, coaches understand their critical position as a role model and leader, and subsequently the importance of their role as an educator of concepts that address gender equity.

Provider Characteristics

Coaches, administrators, advocates, and community members must also believe in the need for and potential benefits from delivering CBIM to their athletes. And, coaches must develop confidence in their ability to deliver curriculum and facilitate discussion. Across interviews, coaches used language and shared examples that demonstrated their appreciation for the gender transformative aspects of the CBIM program. As sports culture is historically a hypermasculine environment, gender inequitable norms may be quite entrenched in behaviors and attitudes of coaches and their athletes alike. Previous research has examined a coach’s role in violence prevention and noted that in-depth training may be needed to avoid coaches transmitting their own problematic values to their athletes (Lyndon et al., 2011).

Coaches desire to develop their athletes psychologically and socially off the field (Gould & Chung, 2006) may be a useful avenue for promoting positive gender equitable attitudes in athletic settings. Seeing positive improvements in their athletes’ bystander behaviors, willingness to intervene when observing inappropriate behaviors, and an increase in positive (more equitable) conversations about women and girls served as positive feedback for coaches’ self-efficacy and proficiency with facilitating sensitive discussions, factors Durlak and DuPre (2008) suggest improve implementation and encourage implementers to sustain the program in the future. Observations and post-season surveys were not a component of this study; thus, we do not have additional evidence of impact on these coaches’ teams. In this community-based evaluation, coaches described multiple strategies to make the topics accessible and relatable for their athletes. It is possible that the changing landscape around public discussions of sexual harassment (such as the #MeToo movement) has also encouraged coaches to feel more comfortable raising these significant topics. Mention of the #MeToo movement and “certain things” happening in school, as coaches reported during interviews, suggest that coaches may be becoming more readily aware of incidents of sexual misconduct occurring with their athletes (and their peers). Further studies of program implementation should also assess the extent to which coaches translate awareness of sexual harassment into actual changes in language, attitudes and behaviors as well as their comfort with challenging gender inequities.

Characteristics of Innovation

Having acknowledged the need for programming, cultivating community support, and providing consistent training, the programming coaches deliver should be compatible and adaptable to their athletes and their community. When CBIM was developed, the cards were designed to build upon one another with more complex topics appearing later in the season. Coaches strived to keep the material relevant and interesting to their athletes using various strategies including integrating discussions of current events, personal narratives, and school-related events.

Even so, adaptability of a program is key for sustainability and coaches noted the importance of having autonomy and flexibility for engagement in the program. Coaches reported that they often switched the order of the card delivery to discuss certain topics at relevant times. As previous research demonstrated improved outcomes when more training cards were covered during a sports season (Miller et al., 2012), attention to fidelity to intervention should be balanced carefully with coaches’ desire for having an adaptable and flexible program. The randomized controlled trial of CBIM with high school students showed no changes in attitudes (Brush & Miller, 2019; Miller et al., 2012), whereas a middle school trial of CBIM found increases in gender-equitable attitudes at 1 year follow up were directly proportional to intervention intensity and dosage (Miller et al., 2020). That is, the more training cards that coaches delivered and the more complete the program package (at least 8 of the 12 cards delivered), the higher the middle school male athletes scored on measures of gender-equitable attitudes (Brush & Miller, 2019; Miller et al., 2012, 2020). This certainly suggests that, at least for younger adolescents, if implemented relatively completely, the program shifts gender attitudes towards equity. Thus, encouraging coaches to complete the full curriculum as intended remains a key challenge for implementation.

Ease of using the cards and the flexibility to be able to integrate discussions of current events were identified as key factors for program implementation both in the prior research study (Jaime et al., 2018) as well as in this community-based dissemination effort. Lack of time to train, prepare, and deliver CBIM remains the most commonly cited barrier for coaches – a barrier which can only be overcome if coaches, advocates, and administrators commit to consistently making time for programming. This commitment will take the collaboration of coaches, advocates, and administrators devising viable methods to integrate CBIM sessions into their sports routines while keeping materials interesting and relevant.

Given coaches concerns about redundancy of the program as they start another sports season (e.g., for athletes who play sports in both the fall and spring seasons, and for those who are involved with the same coach for several years in a row), creating booster trainings between implementation years could provide opportunity for coaches to share ideas for program delivery, develop and maintain coach-coach and coach-advocate relationships, and to delve more deeply into discussions about gender equity with their athletes and community.

Limitations

As a small-scale qualitative study, this research has several limitations. Qualitative studies of this nature come with selection and participation bias, as we spoke to coaches who implemented at least some aspect of the program and found the experience meaningful enough to provide us with their input without an incentive. A lack of coach buy-in to CBIM will greatly affect implementation, as provider characteristics are a well-recognized category affecting implementation. By interviewing coaches who were familiar with and implemented at least some portion of CBIM curriculum, we were able to explore beyond the coaches’ willingness to deliver the program and explore other levels of the athletic ecosystem that may influence implementation beyond the coach. All coaches work within Southwestern Pennsylvania but did include schools from surrounding (more rural) counties. Thus, findings are not generalizable to other geographic regions and as a qualitative study these findings are not meant to be representative. Further research is needed to better understand the experience of those coaches who were not interviewed to elucidate ways to increase engagement from the start. Coaches were told that the interviews were anonymous but may have responded more positively about the program due to social desirability bias. Similarly, the race and gender of interviewers may have influenced how coaches responded to interview questions. The use of language like “stuff that happened” and “#MeToo” may indicate a reticence among coaches to explicitly address instances of teen dating violence, sexual misconduct, and gender inequitable attitudes and behaviors. Additionally, the researcher team has extensive background in intersections of race, gender, and sexual misconduct, which may have introduced biases during coding and analysis. Understanding of how successful the implementation was also coming solely from coaches’ perceptions and recollections (i.e., recall bias), as objective outcome data or observations were not included in this analysis. For the purpose of this analysis, coach satisfaction and completion of most of the cards translate to subjective success, but further research that uses observation of sessions can add perspective to this subjective feedback to understand what is really happening when coaches are delivering CBIM. Interviews were only conducted with coaches and it is important to note that they are just one component of CBIM. These findings would be better understood if combined with the perspectives of athletes, athletic directors and advocates. Implementation is dependent on all of these parties and hearing from each would best inform efforts to understand how to ensure successful implementation, for exploration in future studies.

Conclusion

Coaches provided insights into implementation of CBIM within a community-based high school sport setting. These results inform best practices for CBIM delivery through a discussion of the barriers for which there are manageable solutions. With appropriate supports in place, coaches are able to implement the program, identify positive impacts among their athletes, and help transform sports into a platform for community-wide violence prevention. These findings will help inform how best to assist coaches starting to implement CBIM, and highlight the need for community-wide support – from administrators, advocates, community members, coaches, and athletes – to improve the dissemination and implementation of CBIM. Extending beyond CBIM, understanding the implementation process of various public health interventions is a vital component of the research that cannot be omitted following an effectiveness study. For an intervention to provide its intended benefit in a community, assessing implementation at multiple levels will provide an opportunity to make adjustments necessary for program success and sustainability.

Supplemental Material

Supplemental Material - A Coach-Delivered Dating Violence Prevention Program: Coach Perspectives on Implementation

Supplemental Material for A Coach-Delivered Dating Violence Prevention Program: Coach Perspectives on Implementation by Mikaela Fenn, Lisa Ripper, Alana D. Fields, Ashley Hill, Paul Mulbah, Nicolás Matheo Kass, and Elizabeth Miller in Journal of Interpersonal Violence

Footnotes

Acknowledgments

The authors wish to acknowledge the many coaches, athletes, and school districts that participated in this study. They also wish to acknowledge the Southwestern Pennsylvania Coaching Boys into Men Community of Practice for their support.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the United Way of Southwestern Pennsylvania.

ORCID iDs

Lisa Ripper

Alana D. Fields

Ashley Hill

Elizabeth Miller

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Mikaela Fenn, BS, is a fourth-year medical student at the University of Pittsburgh School of Medicine. She is studying to become a community primary care physician to address the physical, mental, and social health of her patients. She is interested in studying implementation of violence prevention programs with hopes to be an influential partner in enacting social change.

Lisa Ripper, MPH, CPH, is the Community Health Research Manager in the Division of Adolescent and Young Adult Medicine at UPMC Children’s Hospital of Pittsburgh and the University of Pittsburgh School of Medicine. Her research focuses on adolescent violence prevention programs and school and community health.

Alana D. Fields, PhD, is a Postdoctoral Research with UPMC Children’s Hospital of Pittsburgh. Her research focuses on sociological, theoretical, and intersectional approaches to violence prevention. She hopes that her career can aid in the rehabilitative process with women and children who have endured experiences of sexual assault and domestic violence. She continues to advocate, mentor, and support the education of underserved minority populations.

Ashley Hill, DrPH, MPH, is a Postdoctoral Researcher with UPMC Children’s Hospital of Pittsburgh. Her research focuses on reproductive epidemiology, health disparities and the co-occurrence of social, environmental and biological factors that increase sexually transmitted infections. As a postdoc, her primary projects investigate the implication of relationship violence on girls and women’s reproductive health.

Paul Mulbah, BS, is a Violence Prevention Specialist with the University of Pittsburgh and UPMC Children's Hospital of Pittsburgh. His work is based around engaging young men in domestic violence and sexual assault prevention. He has aided in helping Southwestern PA to become the leader in implementing Coaching Boys into Men. He also works in similar capacities with collegiate and professional athletes.

Nicolás Matheo Kass, BA, is a student at the University of Pittsburgh School of Medicine. His research interests include examining the implementation of community health programs, including the prevention of sexual and gender-based violence, best practices for creating a welcoming environment for LGBTQ Latino youth in health care clinics, and evaluating the bi-directional communication of the brain and gut.

Elizabeth Miller, MD, PhD, is Edmund R. McCluskey Chair of Pediatric Medical Education and Professor in Pediatrics, Public Health, and Clinical and Translational Science at the University of Pittsburgh School of Medicine and Director of the Division of Adolescent and Young Adult Medicine, UPMC Children’s Hospital of Pittsburgh. Her research addresses interpersonal violence prevention and adolescent health promotion in clinical and community settings.

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