Using a Multicomponent Implementation Strategy to Increase Adoption and Effectiveness of a Universal Mental Health Prevention Program in Australian Primary Schools: a Cluster Randomized Trial Using a Type-3 Hybrid Design.

Early program adoption was significantly higher in the intervention group (receiving PAX GBG plus implementation toolkit) compared to the control group (PAX GBG only) at 6 weeks post-registration.

• Adoption rates at 6 weeks: 93.6% in intervention group vs 45.2% in control group.
• OR = 21.20, 95% CI [3.50, 128.45], z = 3.32, p < 0.001.
• Adoption was measured as current use or support of the PAX Good Behavior Game.
• The trial was conducted in 25 primary schools across New South Wales, Australia.

There was no differential effect on program adoption between the intervention and control groups at 6 months post-registration.

• Adoption rates at 6 months: 96.8% in intervention group vs 95.7% in control group.
• OR = 1.21, 95% CI [0.16, 9.04], z = 0.18, p = 0.855.
• Both groups converged to near-complete adoption by 6 months.
• Data were analyzed using intention-to-treat methods.

Students' emotional and behavioral problems decreased significantly from baseline to 6 months across both groups combined, but there was no differential effect between groups.

• Both groups showed significant reduction in emotional and behavioral problems from baseline to 6 months: p < 0.001, d = -0.25.
• No differential effect was observed between groups at 6 months: p = 0.474, d = -0.08.
• Emotional and behavioral problems were measured using the teacher-reported Strengths and Difficulties Questionnaire (SDQ).
• The first SDQ measurement occurred at trial registration, prior to program implementation.

There was a positive linear relationship between program adoption and the perceived acceptability, appropriateness, and feasibility of the PAX Good Behavior Game for the pooled sample.

• This relationship was observed for the pooled sample across both intervention and control groups.
• The finding suggests that perceptions of the program's fit and practicality are associated with higher adoption rates.
• Acceptability, appropriateness, and feasibility were measured as implementation outcomes in the trial.

The study used a type-3 hybrid implementation-effectiveness design with a cluster randomized controlled trial in primary schools.

• 25 primary schools in New South Wales, Australia were included.
• Schools were randomly assigned to PAX GBG plus an implementation toolkit (intervention) or PAX GBG only (control).
• The primary outcome was change in rate of program adoption measured at 6 weeks (T0) and 6 months (T1) post-registration.
• The protocol was retrospectively registered with the Australian New Zealand Clinical Trials Registry, ACTRN12621001125819.

The PAX Good Behavior Game has been demonstrated in multiple randomized trials to reduce the severity and progression of childhood emotional and behavioral problems prognostic of mental disorders, personality disorders, and self-harm in adolescence and early adulthood.

• The program targets childhood emotional and behavioral problems in primary school settings.
• Prior evidence indicates effectiveness for preventing mental disorders, personality disorders, and self-harm behavior.
• Embedding such effective programs into routine practices of frontline settings is described as a global priority for mental health prevention.
• Little is known about what strategies effectively support program implementation in schools.