Adapting TeachABI to the local needs of Australian educators – a critical step for successful implementation

Background

Acquired brain injury (ABI) is a significant global concern, recognised as a leading cause of paediatric death and disability by the World Health Organization (WHO 2006). In Australia alone, at least 99,000 children live with a disability resulting from ABI (Australian Bureau of Statistics 2018). ABI can lead to acute and persisting impairments across physical, cognitive, and psychosocial domains with outcomes varying greatly depending on individual injury and child related factors (Chapman 2006; Demellweek et al. 2006; Forsyth and Kirkham 2012; Babikian et al. 2015). The lasting and evolving impact of ABI on academic performance and school participation is well-documented (Taylor et al. 2008; Catroppa et al. 2009; Anderson et al. 2012; McKinlay and Buck 2019; Goh et al. 2021; Mitchell et al. 2021). Returning to school is a primary rehabilitation goal for the majority of children with an ABI and their families. Upon their return, the school environment becomes a major ‘de-facto’ site of rehabilitation for children with ABI, with educators, even unknowingly, playing a pivotal role in their cognitive and psychosocial recovery (Bate et al. 2021). Educators’ understanding of ABI is associated with quality-of-life outcomes, including the facilitation of a sense of belonging and inclusion in the classroom for children with ABI (Wlodarczyk 2012). Additionally, educator responses to students with ABI are a central factor in whether the child, and their family, feel return to school was successful (Hartman et al. 2015). Families, however, frequently raise concerns regarding the limited awareness of the unique needs of children with ABI amongst educators, which is perceived to contribute to misconceptions about, and underestimation of, children with ABI, insufficient recognition of hidden challenges, and inadequate implementation of required adjustment recommendations in the classroom (Mealings et al. 2012; Hartman et al. 2015; Andersson et al. 2016). Most educational professionals are not equipped with an adequate understanding of ABI to appropriately and confidently meet the needs of children with ABI in the classroom (Menon and Bryant 2019). Internationally, educator knowledge of ABI is characterised by gaps in understanding regarding the cognitive, behavioural, and social outcomes associated with ABI and the recovery process for children with an ABI (Farmer and Johnson-Gerard 1997; Linden et al. 2013; Ernst et al. 2016). In the local Australian context, misconceptions primarily pertain to the lasting effects and impact of ABI on cognition and psychosocial functioning (McKinlay and Buck 2019). Less than a third of Australian educators report undergoing any training related to ABI and the majority are uncertain of where to access additional information, resources, or support (Buck and McKinlay 2021). Importantly, educators are aware of their lack of knowledge regarding ABI and want access to further training opportunities (Buck and McKinlay 2021).

Poor understanding of ABI within the education system is a public health issue, with a global call for action emphasising the need for reform (McKinlay et al. 2016; Menon and Bryant 2019). Despite the prevalence and recognised impact an ABI can have on educational outcomes, there are no universally available service provisions or training resources readily accessible to educators and whilst statewide rehabilitation services have developed educational resources, these are fragmented and unstandardised across sites (McKinlay et al. 2016; Buck and McKinlay 2021; Mallory et al. 2022). Current Guidelines for Service Provision for Children with ABI (International Paediatric Brain Injury Society (IPBIS) Recommendations) identify education as a primary target for improvement (McKinlay et al. 2016). The provisions emphasise the importance of educating teaching professionals about the distinctive characteristics and learning abilities of students with ABI and strongly advocate for the design and distribution of ABI-accessible training modules to support the professional development (PD) of educators in this area (McKinlay et al. 2016).

TeachABI professional development module

TeachABI is an online PD module designed to bridge the ABI knowledge gap among primary-school educators in Ontario, Canada (Stevens et al. 2021; Saly et al. 2023). This 1-h module uses a case study approach, with embedded videos and supplementary resources, to provide educators with an understanding of ABI and strategies to support accessibility and inclusion in the classroom for primary school students with ABI. The Canadian module underwent an extensive development phase informed by a combined framework for curriculum development including Kern’s Six-Step Approach to Curriculum Development (Kern et al. 2009) and the Knowledge-to-Action (KTA) Cycle (Graham et al. 2006) (for detail see Saly et al. 2023). Ontario primary school educators expressed high satisfaction with the usability, content, and delivery of TeachABI (Saly et al. 2023).

TeachABI-Australia

TeachABI-Australia is a component of the wider TeachABI module development and implementation process, which follows an integrated knowledge translation (iKT) approach, guided by KTA, a dynamic, iterative process of knowledge co-creation and dissemination involving knowledge-users throughout the entire research process (Graham et al. 2006; Andrews et al. 2012).

The objective of the TeachABI-Australia project is to implement the module into the Australian educational setting and clinical practice. The initial phase of this project is centred on adapting the original module content and resources to develop an iteration of the module that is acceptable to Australian educators, therefore creating TeachABI-Australia. Adaptation, defined as the systematic planning of modifications to the design or delivery of an intervention to suit the specific requirements of a new context, is a critical component of the implementation action cycle, ensuring the social validity, acceptance, and overall alignment of the intervention within the unique local setting (WHO 2016; Graham et al. 2006; Movsisyan et al. 2019). Alignment refers to the process of ensuring fit between an intervention and the outer (e.g. societal, cultural and legislation) and inner, organisational elements, of a system. Ensuring alignment between the TeachABI module and the Australian education system is critical, given the pluralistic nature of school reintegration for children with an ABI, which requires liaison between hospitals, schools, families, and outpatient services (Ford et al. 2006; Aarons et al. 2011; Hartman et al. 2015; Lindsay et al. 2015).

The ADAPT guidance is a published synthesis of recommendations to improve content and consistency of reporting of intervention adaptions (Moore et al. 2021). The ADAPT process model outlines four steps in the adaptation process. Step 1: assess the rationale for intervention, and consider intervention-context fit of TeachABI-Australia has been completed through the initial development of TeachABI in Canada (Saly et al. 2023). The focus of the current study is on Step 2: plan for and undertake adaptations (Moore et al. 2021, p. 5). Despite being a critical antecedent for successful implementation, methodological guidance for intervention adaptation processes within the field of paediatric ABI is limited (Sundell et al. 2016; Davey et al. 2018; Wade et al. 2021). Thus, the systematic process of adaptation detailed in this study may provide guidance for future international adaptations of the TeachABI module. In this study, the aims were to: (1) assess whether the TeachABI module is suitable and acceptable to Australian educators, and (2) determine required modifications to ensure the module aligns with the local Australian context.

Framework and design

This study was approved by the Royal Children’s Hospital ethics committee (HREC/87116/RCHM-2022). The current study is the initial phase of a wider iKT project, informed by the KTA cycle, to develop and implement an Australian iteration of the TeachABI module (Graham et al. 2006). The overarching adaptation process for TeachABI-Australia follows the recommended process outlined in the ADAPT guidance process model (Moore et al. 2021). Accordingly, a consulting advisory group of key community partners was established to steer the adaptation process. The study design for the current study was modified from The Method for Program Adaptation through Community Engagement (M-PACE) which details processes for obtaining high-quality feedback from participants regarding planned adaptations to an intervention, including: (1) exposing the complete unadapted intervention to a cohort of relevant end users (educators) and, (2) collecting participant feedback to collate recommended changes to the intervention (TeachABI module) (Chen et al. 2013).

Using a convergent parallel mixed-methods approach, qualitative and quantitative data of participants’ feedback of the unadapted TeachABI module were collected concurrently (Creswell and Plano Clark 2011).

Materials

Post-module feedback

Semi-structured interview

The semi-structured interview guide was developed based on the integration of three implementation evaluation frameworks: the Consolidated Framework for Implementation Research (CFIR; Damschroder et al. 2009), the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME; Stirman et al. 2019), and the Intervention Mapping for Adaptation framework (IM-Adapt; Highfield et al. 2015) (see Supplementary Table S1). These frameworks were selected to address different components of the research questions and nuances of adaptability. Broadly speaking, questions pertaining to the adaptability, implementation, and overall evaluation of the module (e.g. understanding if TeachABI can be feasibly and successfully implemented into the participants particular setting) were captured under the CFIR. Suitability (e.g. understanding if the module has good fit with the participants behavioural, environmental, and cultural context and identifying the extent to which adaptations are required) was primarily addressed through questions derived from the IM-Adapt framework. The FRAME was used to develop questions to assess and document the required modifications to the module. The interview guide captures five broad topics derived from the frameworks; impressions, quality, improvement, suitability, and implementation (see Supplementary Table S2).

Sampling and recruitment

A purposive sample of eight primary school educators was recruited to ensure a diverse range of perspectives across locations, roles, school settings, and experience teaching children with ABI (Palinkas et al. 2015). Recruitment methods included poster circulation via email to individual networks of the advisory group members and online educator networks. Stopping criteria for data saturation was set at <5% novel information arising from two consecutive transcripts, calculated using Guest et al.’s (2020) approach. Participants were eligible if they were registered as a primary school educator. Participants who were non-English speaking or had visual, cognitive, or physical impairments that would necessitate accommodations to use the TeachABI module were excluded from the study.

Additionally, a TeachABI-Australia Community Advisory Group (n = 14) consisting of paediatricians, neuropsychologists, young people, and parents with lived experience of paediatric ABI, non-profit ABI community organisation representatives, and special education teachers was established and met on a quarterly basis throughout the research process to guide research design, recruitment, and provide additional feedback on the module.

Procedure

Participants completed one 2-h study session over Zoom which included a demographic survey through RedCap, completion of the module via Zoom screensharing, a post-module feedback survey (RedCap), and a semi-structured interview (Harris et al. 2009.)

Data analysis

Interview transcripts were coded using a directed inductive content approach. The directed content approach followed a coding scheme developed using the CFIR, IM-Adapt, and FRAME (Hsieh and Shannon 2005; Damschroder et al. 2009; Highfield et al. 2015; Stirman et al. 2019). Inductive content analysis was employed to ensure additional data not covered by the initial coding scheme was adequately captured (Vears and Gillam 2022). Analysis involved an iterative process of assigning pre-determined codes for deductive analysis and developing new codes inductively until data saturation was reached. Data was analysed with the aid of audio-coding facility, NVivo (ver. 12, QSR International). Data collection and analysis was accompanied by reflective journal taking (Ortlipp 2008). A randomly selected sub-set of three transcripts was coded by a second researcher (MW) who met with the lead coder (MD) to ensure internal consistency and refine the meaning and application of coding. MD maintained an audit trail in their journal to document the team’s coding process. Descriptive statistics were calculated to analyse the quantitative demographic (mean, range) and survey (median and interquartile range) data using RStudio Team (2020). Fig. 1 provides an overview of the study design and novel adaptation approach.

Fig. 1.

TeachABI-Australia Adaptation Study Design. CFIR, Consolidated Framework for Implementation Research (Damschroder et al. 2009); FRAME, Framework for Reporting Adaptations and Modifications (Stirman et al. 2019); IM-Adapt Intervention Mapping for Adaptation framework (Highfield et al. 2015); TFA, Theoretical Framework for Acceptability (Sekhon et al. 2022). The role of the advisory group is reflected as an umbrella assisting throughout the adaptation process; in study design, recruitment of participants, and providing additional recommendations for the adaptation of the module. Grey shading indicates the KTA model used for the overall study process of TeachABI-Australia. ^aSee Supplementary material for further detail.

Participant demographics

Descriptive data of the participants is described in Table 1. Participants had a range of teaching backgrounds and roles within the education system across regional and metropolitan Victoria, Queensland, and Western Australia. Participants had a mean of 24.88 years of teaching (range: 10–40 years). Five of the participants had worked with a child with ABI in some capacity; however, of those participants, only two indicated they had received prior ABI training.

Post-module feedback

Overall, responses from the generic TFA questionnaire indicated that the module was ‘Completely Acceptable’ to participants (Mdn = 5, IQR = 1). Table 2 shows the median and interquartile range (IQR) for each question on the TFA questions in the post-module feedback survey. Additionally, all participants ‘Agreed’ or ‘Strongly Agreed’ that the module was a valuable resource for Australian educators (Mdn = 4, IQR = 0.25), and that ‘only Minor’ changes to the module were needed to suit the local Australian educational context (Mdn = 2, IQR = 0.25).

Qualitative results

Three distinct overarching categories arose from qualitative analysis of the interviews: (1) the usefulness of TeachABI, (2) the local fit of TeachABI, and (3) pathways for implementing TeachABI in the local setting. Representative quotations to illustrate main findings in each category are provided in Table 3, with quotations for the sub-category ‘recommendations for modifications’ presented in Table 4 (Eldh et al. 2020).

Adapting TeachABI: fit and required modifications

As an essential step in successful implementation, the present study sought to systematically identify modifications required to adapt the TeachABI module to best fit the novel Australian context whilst maintaining the fidelity of the original resource (Backer 2001; Highfield et al. 2015). Overall, educators believed the delivery and majority of the instructional content surrounding strategies for ABI in the classroom fit well within the local context. Therefore, when making the Australian iteration of TeachABI, these components will be considered as essential elements of the intervention to be retained (Highfield et al. 2015). Whilst content pertaining to the behavioural operations of schools and classroom teachers was well aligned with the schooling systems of Australian educators, cultural and environmental aspects of the Australian context were not adequately reflected in the module, resulting in reduced perceived authenticity.

Educators desired for the module to address the complexities inherent in the coordination of services for a child returning to school after ABI in the Australian health and educational sectors and recommended including the addition of topics pertaining to the hospital-to-school transition, information regarding relevant supports, and explanation of the role of specialist clinicians such as hospital teachers and neuropsychologists. Reintegration into schooling following ABI involves a nuanced and complex coordination of services, organisations, and relevant parties (Sharp et al. 2006; Hartman et al. 2015). Findings from our study indicate that PD resources developed for this context should endeavour to capture these processes. Adapting the content and provided resources in the TeachABI module to the unique operations of the Australian healthcare and education systems would facilitate improved likelihood of successful implementation in the Australian setting (Lundmark et al. 2021).

Developing TeachABI-Australia: a co-design process

TeachABI demonstrated a low perceived burden and was valued for its interactivity, accessibility and cost-effectiveness, consistent with the benefits of online educational interventions established in the literature (Sinclair et al. 2016). These finding are comparable to the initial Canadian TeachABI usability study which found high satisfaction with the module’s usability and relevance of the content and strategies to the realities of their teaching profession (Saly et al. 2023). TeachABI employed a comprehensive co-design process that ensured the module was designed for educators by educators, and the value of this approach is illustrated by the current finding that the module’s content and delivery resonates with the needs and preferences of educators across settings.

Ensuring relevant knowledge-users and community representatives are involved in the co-creation process remains a priority in developing an Australian version of the TeachABI module. The TeachABI-Australia project utilises an iKT approach to the development and implementation of TeachABI in the local Australian context to ensure relevancy, acceptability, and improve the adoption and impact of the module (Andrews et al. 2012). This approach to resource development is relatively novel in paediatric ABI research; however, by drawing on existing methodological approaches in the prevention science literature, this study has provided a detailed guide to the adaptation stage of the KTA cycle which can be modified and applied to future international iterations of the TeachABI module (Chen et al. 2013; Boland et al. 2020).

Pathways for implementation

Educators provided reflections on the possible implementation pathways for TeachABI in their setting. TeachABI was considered a useful and important resource for educators, but it was unclear whether it should be part of training for all educators regardless of whether they are currently working with a student with ABI or if it should be introduced at point-of-need. Given that ABI is a major cause of disability, most teachers will work with a child with ABI at some point in their careers and thus there is a strong case that ‘all educational professionals should have a minimum level of awareness and understanding about ABI and the educational requirements of children with this condition’ (Ilie et al. 2013; Menon and Bryant 2019, p. 28). The IPBIS Service Provisions discuss similar pathways for ABI education, suggesting the teacher training curriculum focus on educating professionals about the needs of children with an ABI through accessible online modules and recommend that educators who work with children with an ABI be required to show proof of accredited ABI training (McKinlay et al. 2016).

Conversely, educational resources such as TeachABI may be especially relevant in the hospital-to-school transition process, where educators actively seek information about ABI and perceive lack of training as a direct barrier in their successful facilitation of school re-integration (Hartman et al. 2015). Within this setting, adoption of TeachABI is supported by healthcare professionals and educational liaisons who may be helpful in facilitating the conversation around PD (Hinton and Kirk 2015). Moreover, the immediate applicability of the module offers educators a means to gain direct insight from their experiences with the child (Korthagen 2017). The feasibility of these pathways for TeachABI implementation requires further exploration with key decision makers in education departments, university training programs, and health organisational bodies.

Strengths and limitations

This study demonstrates the value of applying a systematic methodological approach informed by iKT principles and adaptation guidelines when developing and implementing local iterations of an intervention. Despite the limited literature available to guide the study design, this research offers a valuable model for the methodological approach of the plan for and undertake adaptations stage of adaptation, adhering to the ADAPT Guidance and M-PACE methods (Chen et al. 2013; Moore et al. 2021). Furthermore, utilising implementation frameworks to guide the semi-structured interviews and coding schemes allowed for targeted deduction of the specific areas that require modification to ensure the module is suitable and useful to knowledge-users in the local Australian context.

We employed purposive sampling to gain diversity of perspectives across school settings, locations, and teaching experience but it is important to acknowledge that the majority of those who expressed interest had some level of prior experience working with ABI, although this ranged from 1 month to 15 years. This may have impacted participant attitudes towards TeachABI, as educators who are not familiar with the unique learning needs of children with ABI may not be aware of the necessity for specialised training. Additionally, data saturation techniques were employed to adequately capture the depth and breadth of participant feedback; however, the relatively small sample size required to reach saturation stopping criteria suggest the sample obtained in this study may have been relatively homogenous (Guest et al. 2020; Hennink and Kaiser 2022). The present study did not capture perspectives of educators working with First Nations children in rural and regional Australia, as a separate adaptation study with unique methodological approaches dedicated to co-design within this population is required (Hill et al. 2020; Wade et al. 2021). A strength of the iterative nature of iKT processes is that this study represents the start of the local ‘conversation’, and further consultation with community educators across all states and territories, advisory group members, and relevant actors is planned to address this limitation and ensure generalisability of the module within the Australian context (Field et al. 2014).

Future directions: adaptation to implementation

Within the adaptation process, the next phase involves evaluation of the feasibility, importance, and congruence of the recommended adaptations in consultation with the TeachABI Community Advisory Group (Chen et al. 2013). The perspectives from this study and recommended changes will be fed back into the creation phase of knowledge co-design and a new iteration of TeachABI will be developed. Additionally, the implementation avenues for TeachABI integration will be explored through further consultation and research to assess the feasibility and determinants of implementation in each of these settings. This pre-implementation planning is a necessary future step to ensure successful adoption of TeachABI in Australia.