• Research questions pertaining to sustaining the program once it is introduced in a service system. The ability to sustain a program relates to the organizational structures, practices, data monitoring, leadership, and related characteristics in place in the home institution for the program.

  • Research questions involving moving to scale, or understanding which steps facilitate the structures and funding necessary to expand the program to other sites.

There are major challenges of introducing and taking effective programs to scale, particularly in poor and underserved communities (Madon, Hofman, et al., 2007; Sanders and Haines, 2006), and clearly the current body of generalizable knowledge is inadequate to provide robust strategies for effective implementation across different populations, systems, and programs. Nevertheless, there is reason for optimism.

First, the dearth of generalizable knowledge is a product of the lack of significant investment in scientific studies of the implementation and dissemination process. Second, while the specific factors regarding successful program implementation may vary from case to case, there are many commonalities in why organizations have difficulties adopting and sustaining prevention programs. For example, poor communities, minority populations, and developing countries often lack professionally trained staff to deliver a program as originally designed, so successful implementation may need to identify unique program delivery agents using existing resources (Sanders and Haines, 2006). Also, there is general agreement in the field about shared dimensions of organizational change that are relevant across widely different interventions; these include system readiness for change, culture, and the role of leaders (Chambers, 2008). Third, the increasing use of more rigorous designs, such as randomized trials that test different implementation strategies (see Chapter 10), social network analysis (Chambers, 2008), and the combined use of qualitative and quantitative data, is likely to lead to more precise implementation inferences around shared research questions. This information can be used as markers to guide the development of successful implementation efforts across diverse fields and settings.

Implementation research turns the traditional efficacy/effectiveness research questions of prevention science into experimental questions about the process of implementation itself. To date the leading model for examining implementation of prevention programs has been to focus on a single region, such as an urban school district or an entire state. With this approach, one can examine how process factors affect the adoption of a program over time, even if there are unique or novel factors operating in that particular system (Biglan, 2004). In addition, some randomized trial

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