emotional health. Such approaches would facilitate coordination of all the children’s health care needs and reinforce the integral nature of physical and mental health care needs.

IMPLEMENTATION CHALLENGES

Fixsen, Naoom, and colleagues (2005) note that “[successful] implementation is synonymous with coordinated change at system, organization, program, and practice levels.” This coordination is not easy to achieve, and indeed these authors note that poor implementation of a beneficial program can come from unsupportive policies or regulations or a lack of funding opportunities at the federal, state, or local level; a lack of organizational commitment, capacity, or leadership; poorly chosen or high turnover among intervention agents or practitioners; or a lack of involvement in or ownership in the program by the community. Until recently there has been little support from the federal or state governments for prevention activities and even less for building an infrastructure that facilitates these efforts. It is also often difficult to sustain attention on a specific problem, as evidenced by the current lowering of priorities for HIV prevention and youth tobacco prevention (U.S. Government Accountability Office, 2007; Institute of Medicine, 2006b).

Coordinating all these issues would be difficult enough if policy makers, organizations, practitioners, community leaders, and consumers all spoke the same language and shared a common vision. However, these groups often have vastly different world views and priorities and are often reluctant to learn about each others’ perspectives.

The previous sections have described some key challenges to the implementation of preventive interventions, including the need to balance cultural adaptation and fidelity, the difficulty of forming essential community-research partnerships, and the time lag between documentation that an implementation is effective and its successful adoption. This section reviews additional implementation challenges: funding; service system priorities; training, monitoring, and capacity building; data systems; low participation and retention rates; and organizational context.

Funding

Obtaining adequate funding is a challenge for all types of implementation. Program cost, including the cost of labor, materials, and technical assistance, is often just as or even more important to communities and policy makers than effectiveness. Yet not only are evaluations of the benefits and costs of prevention programs relatively uncommon (see Chapter 9), but also collection of cost data is as well. In one analysis of prevention pro-



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