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Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda (2019)

Chapter: 8 Effective Implementation: Core Components, Adaptation, and Strategies

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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Page 200
Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Suggested Citation:"8 Effective Implementation: Core Components, Adaptation, and Strategies." National Academies of Sciences, Engineering, and Medicine. 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. doi: 10.17226/25201.
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Prepublication Copy, Uncorrected Proofs Chapter 8 8 Effective Implementation: Core Components, Adaptation, and Strategies Implementation is sometimes compared to an engineering process because it requires a combination of methods and tools that are based in research but intended to guide a complex, real-world activity with many moving parts. As one expert told the committee, implementation is “about making things work, not discovering whether they could work.”37 The purpose of careful implementation is to take initiatives from the research stage into widespread practice in a way that ensures fidelity to the original concept and achieves the desired outcome (Fixsen et al., 2009). Effectively implementing a program on a broad scale is a process that takes time and requires ongoing evaluation and adaptation to local circumstances (Aarons, Hurlburt, and Horwitz, 2011; Metz and Bartley, 2012; Meyers, Durlak, and Wandersman, 2012). There are several prerequisites to effective implementation. The program needs to be based on a sound theoretical model that characterizes precisely how it can be expected to bring about a desired change. Evaluation then produces data that can be used to refine the program’s design and establish the parameters for delivering it with fidelity; Box 8-1 defines the dimensions of fidelity that need to be considered. BOX 8-1 Dimensions of Implementation Fidelity Primary dimensions of fidelity in the implementation of a program or intervention include adherence, quality, participant engagement, and dosage:  Adherence refers to whether core intervention components are being delivered as designed or written (i.e., to the appropriate population; by staff trained appropriately in the logic models through which these core components effect the desired outcome; using the right protocols, techniques, and materials; and in the locations or contexts prescribed).  Quality denotes the manner in which practitioners deliver the intervention (e.g., skill in using the prescribed techniques or methods, enthusiasm, preparedness, and attitude).  Participant engagement is the extent to which participants are engaged by and involved in activities related to the core intervention components.  Dosage may include the amount of time, number of times, or frequency with which participants receive core intervention components. SOURCE: Developed by the committee based on Dane and Schneider (1998) and Milhalic (2004). During the past decade, implementation research has focused both on the foundations that support the process—the development of a design that highlights essential components needed for effectiveness while allowing for adaptation to suit diverse populations—and the process                                                              37 Brown, personal communication.   178

Prepublication Copy, Uncorrected Proofs Chapter 8 itself—what it takes to deliver an intervention at a scale that can benefit broad populations. Thus, the term scale-up refers to systematic ways of increasing the coverage, range, and sustainability of the intervention, such as by taking a tested, effective local program to the regional, national, or international level (Ilott et al., 2013). This chapter focuses on three elements of sound program design that support effective implementation:  identification of the core components that make an intervention effective and monitoring of the fidelity with which those components are implemented;  adaptation of interventions to suit the needs and characteristics of diverse communities, especially at broader scales; and  the implementation strategies—building blocks—used in mental, emotional, and behavioral (MEB) health–related programs. IDENTIFYING AND MONITORING THE FIDELITY OF CORE COMPONENTS Effective implementation of an intervention starts with identifying its core components and the logic model or theory of how those components are intended to bring about the desired outcome. Also sometimes referred to as the active ingredients, essential elements, or mechanisms of change, core components are those variables that are essential if a program is to function as designed. Examples include the development of particular skills, such as self-management, decision-making, drug resistance, or coping with stress and anxiety (Botvin and Griffin, 2015). Identifying those components that are truly essential makes it possible to then adapt nonessential elements to meet local needs and preferences (Fixsen et al., 2013). Most important, once a program’s core components have been clearly defined, it is possible to implement the program with fidelity, which has consistently been shown to be associated with program effectiveness (see meta-analyses by Dane and Schneider, 1998; Durlak and DuPre, 2008). Ideally, a program’s developers will begin identifying its core components early on, while they are working out the program design, and then monitor the role played by these components as they proceed through efficacy and effectiveness trials, so as to identify the most potent ingredients or mechanisms for change. This process is supported by mediation research, which entails searching for mediating factors—those that explain how the core components actually operate—as well as other factors such as sex, class, or race that moderate those relationships. Mediation studies can also support dissemination by suggesting how interventions might be made more efficient without sacrificing impact. The sections below describe this process in greater detail. Studying Mediating Factors Researchers studying mediating factors in family- and school-based interventions have explored a variety of child and adolescent intervention outcomes, including effects on child conduct problems and externalizing behaviors, school engagement and achievement, depression and anxiety symptoms, initiation of and growth in substance use, and delinquency and arrests (Carreras et al., 2016). Others have explored core skills and intervention targets, such as positive parenting (Bjørknes et al., 2012; Gardner, Burton, and Klimes, 2006; Tein et al., 2006), youth social-emotional character development (Bavarian et al., 2016), and peer refusal skills (Glassman   179

Prepublication Copy, Uncorrected Proofs Chapter 8 et al., 2014). Studies typically examine the role of one or two of many possible mediating mechanisms by which an intervention is thought to work. For example, Sandler and colleagues (2011) examined the mechanisms through which parenting interventions affect child outcomes. Their work suggests that long-term intervention effects are best understood in the context of changes in social, cognitive, behavioral, and biological processes in parents and their children, as well as transactions between youth and their social contexts. Other researchers have used longitudinal studies to examine mediating factors, capitalizing on research designs that can potentially support causal statements by collecting data in three or more waves—examining direct intervention effects first, then targeting mediating constructs, and then measuring longer-term outcomes (Fairchild and MacKinnon, 2014; Gonzales et al., 2014; Leve and Chamberlain, 2007; Lewis, Bailey, and Galbally, 2012; Stigler et al., 2011; Van Ryzin and Dishion, 2012). Several examples illustrate the types of mediators being examined in intervention studies; research of this kind provides clues to the potential core components of interventions. Example: Preventing Adolescent Depression Perrino and colleagues (2014) integrated data from three trials of the family intervention program Familias Unidas to examine mechanisms by which the intervention prevented adolescent depression and internalizing symptoms (negative emotions that are directed inward, such as anxiety or withdrawal). Familias Unidas is a community counseling and information center serving primarily Hispanic families that focuses on increasing positive parenting, family support, and parental involvement and improving parent–adolescent communication. Results of previous tests have found modest to large effect sizes depending on the outcome and trial (Prado and Pantin, 2011).38 Perrino and colleagues sought to understand both how and for whom a specific intervention component might improve adolescent depression and internalizing symptoms, as well as externalizing behaviors (such as aggression or bullying). The researchers focused on the mediating role of one proximal intervention target— parent–adolescent communication—and three moderators—baseline levels of internalizing symptoms, externalizing symptoms, and parent–adolescent communication. They found that the communication component fully mediated intervention effects on levels of internalizing symptoms, particularly among families with lower levels of parent–adolescent communication skills at baseline, providing support for the hypothesis that parent–adolescent communication is an effective component of the Familias Unidas intervention curriculum. Example: Preventing Substance Use in Adolescents DeGarmo and colleagues (2009) sought to test mediators in their study of a universal school-based intervention for early adolescents—Linking the Interests of Families and Teachers (LIFT)—aimed at preventing antisocial behavior, including youth substance use. The intervention focused on proximal intervention targets—strengthening positive relationships between young people and their parents and peers—because of evidence that that these relationships have a protective effect with respect to antisocial behavior and early substance use. Intervention components included parent training, training for children in social and problem-                                                              38 For more information, see http://www.familias-unidas.org.   180

Prepublication Copy, Uncorrected Proofs Chapter 8 solving skills, a recess intervention game (the Good Behavior Game39), and encouraging communication between parents and teachers. The researchers hoped to understand the possible mediating effects of family problem solving and reduction in peer playground aggression on long-term outcomes for the LIFT intervention with respect to initiation and growth of substance use through grade 12. They found that intervention-related effects on reducing average tobacco use were mediated by improvements in family problem solving, while effects on growth in substance use were mediated by family problem solving and reductions in playground aggression. This work highlights that mechanisms and associated program components may play different roles for different outcomes: family training in problem-solving skills and the Good Behavior Game may be critical components for substance use, but family problem solving alone may be sufficient for tobacco use. Example: A Blended Strategy to Address Substance Use and Antisocial Behavior Communities That Care (CTC) is a strategy developed by researchers at the University of Washington for providing workshops, instructional materials, and other resources to communities and states over the Internet.40 CTC uses a blended implementation strategy aimed at developing community-based prevention systems that take advantage of multiple evidence-based programs. Brown and colleagues (2014) assessed the influence of five possible community-level mediators of the effects of CTC on youth substance use and antisocial behavior. The five mediators they examined are core components of CTC’s theory of change with respect to reductions in risk and problem behaviors: community adoption of science-based approaches to prevention, collaboration on prevention initiatives, widespread support for prevention, community norms against drug use and antisocial behavior, and use of the social development strategy in everyday interactions. The researchers found that CTC’s impacts on youth problem behaviors in grade 8 were fully mediated by changes in community adoption of a science-based approach to prevention; none of the other putative mediators had a significant impact. This study is notable for having identified a single core component as the active ingredient in mediating change in CTC’s overall objective of preventing problem behaviors in youth. Another study examined community adoption of the program by surveying community members about their awareness and use of prevention science concepts, use of epidemiologic data, and system monitoring (Cambron et al., 2019). Pinning Down Essential Factors The studies of mediation described above show how the operation of core theoretical constructs can be established and how specific components of an intervention influence long- term outcomes. However, such studies do not provide strong evidence about which components of interventions can be dropped to make the program more efficient. With CTC, for example, the benefits likely occur not solely as a result of half-day orientation sessions for leaders; rather, the training of a well-functioning community coalition to use tools and decision-making processes in selecting evidence based programs and implementing them with fidelity is likely extremely important.                                                              39 For more information, see https://www.goodbehaviorgame.org. See also Box 4-3 in Chapter 4.  40 For more information, see https://www.communitiesthatcare.net.   181

Prepublication Copy, Uncorrected Proofs Chapter 8 Methods for isolating the core components of an intervention more precisely have been proposed. Dismantling or factorial designs (methods for disentangling potentially influential factors) could provide robust evidence about which intervention components are necessary to produce desired effects on youth outcomes and which can be removed to streamline or adapt the intervention (Collins, 2014; Collins, Murphy, and Strecher, 2007; Danaher and Seeley, 2009; Lindquist et al., 2007). One such approach, the Multiphase Optimization Strategy (MOST), uses a three-step process based on engineering principles (Collins and Kugler, 2018; Collins et al., 2005). In the first step, a variety of experimental methods are used to assess an array of interventions or delivery components; a second set of experiments is used to confirm the identification of essential components; and finally, efficacy and effectiveness are confirmed in randomized controlled trials. Other work has also used trials of a range of intervention components to identify those that are essential, beginning with a thorough evaluation of a single multicomponent intervention (Collins, 2014; Collins, Murphy, and Strecher, 2007; Danaher and Seeley, 2009; Lindquist et al., 2007; Mohr et al., 2015). Mediating constructs, such as community adoption of particular prevention strategies, may be complex, so disentangling them into more discrete elements may further illuminate causal mechanisms. Moreover, because many preventive interventions are intended to influence multiple outcomes, potentially through multiple proximal intervention targets, holistic analyses are often desirable. Another approach, the sequential mediation study, explores the operation of an intervention across time to examine possible reactions and complex pathways involving relationships among cognitive, biological, social, and/or behavioral mediators (Deković et al., 2012; Sandler et al., 2011). Monitoring Fidelity Once core components of a program have been established, monitoring of the fidelity with which they are being implemented as the program is being designed and tested is critical. Yet systematic attention to both fidelity monitoring and the role of core components has been neglected in the past and still is (Dane and Schneider, 1998; Jensen et al., 2005; Matthias and John, 2010; Moncher and Prinz, 1991; O’Shea et al., 2016; Prowse and Nagel, 2015). While fidelity monitoring is important in efficacy trials, moreover, it becomes even more so—and more complicated—once an intervention has been put into practice in real-world environments (Crosse et al., 2011). Although the value of consistent quality monitoring has long been recognized, securing the necessary resources and managing the increased burden such monitoring can place on service systems, practitioners, and consumers can be significant challenges (Aarons, Fettes et al., 2009; Aarons, Sommerfeld et al., 2009). Regardless, without data to suggest whether a program has been implemented with fidelity, it is unclear whether program outcomes can accurately be attributed to the program itself or whether poor implementation was a culprit in unexpected outcomes (Fixsen et al., 2013). Researchers have suggested ways to support fidelity assessment in both the research and scale-up stages of an intervention (see Box 8-2). Increasing the connections among clearly identified core intervention components, fidelity assessments, and intended intervention outcomes, as well as ensuring much more rigorous monitoring of core intervention components in both research and practice, may be essential to achieving desired outcomes in everyday practice more consistently. These recommendations also make clear that fidelity monitoring is a   182

Prepublication Copy, Uncorrected Proofs Chapter 8 shared responsibility for implementing organizations or evaluators, supported and reinforced by stakeholders. BOX 8-2 Ways to Support Fidelity Monitoring  Researchers: Identify, measure, and test the efficacy of core program components.  Funders: Include the specification of core components among project deliverables to support both demonstration or pilot testing and quality assurance and improvement efforts.  Decision makers for program adoption: Include among program selection criteria (1) a clear description of core program components; (2) clarity on how core components are connected with expected program outcomes; (3) fidelity assessment tools that are feasible, reliable, and valid; and (4) monitoring mechanisms in place to provide feedback for improvement to program implementers.  Program disseminators: Provide fidelity assessment resources or capabilities with which to monitor the presence of core components during implementation, and clearly comment on potential detriments to intended outcomes when fidelity is low. SOURCE: Adapted from Blasé and colleagues (2013, p. 2). CHOOSING AND ADAPTING PROGRAMS FOR LOCAL COMMUNITIES Although identifying the core components of a program is critical, a growing body of research is emphasizing that programs are more effective and sustainable if they are responsive to local needs, preferences, and capacities (Horner, Blitz, and Ross, 2014; Walker, Bumbarger, and Phillippi, 2015). The diversity of the U.S. population and its communities highlights the importance of careful attention to the distinctive cultural characteristics of communities in implementing interventions related to MEB health at scale (Bernal, Jimenez-Chafey, and Domenech Rodriguez, 2009), particularly given the disparities in both access to care and outcomes for minority populations and those who live in underresourced communities (Alegria, Vallas, and Pumariega, 2010; Alegria et al., 2015; Coker et al., 2009). Adapting programs to suit the local context requires care, however. The 2009 National Academies report notes a “long-standing consensus that health promotion and prevention programs should be culturally sensitive” (National Research Council and Institute of Medicine, 2009, p. 302), and that adapting programs for cultural groups while maintaining their core components has yielded significant benefits. The report’s authors observe that a culturally sensitive intervention has content that is welcoming to the target culture, is not offensive, and comes across as familiar to the people involved. However, they also describe the tension between making adaptations and preserving the elements essential for effectiveness, and note the limited research on cultural, racial, and ethnic issues related to adaptation of interventions. In general, assuming that the selected program accords with the needs and values of the local context in which it is to be implemented and that its core components have been identified, adaptations are most likely to have sustainable impact when they are based on evidence that they align with the   183

Prepublication Copy, Uncorrected Proofs Chapter 8 program’s goals and theory (Aarons et al., 2012; Castro and Yasui., 2017; Chambers, Glasgow, and Stange, 2013; Durlak and DuPre, 2008).41 Frameworks for Cultural Adaptation Over the past two decades, researchers have developed several frameworks for cultural adaptation. For example, the Ecological Validity Model describes eight dimensions to be considered: language, persons, metaphors, content, concepts, goals, methods, and context (Bernal, Bonilla, and Bellido, 1995), and ADAPT-ITT provides a process framework for steps in adaptation, such as assessment to understand the target population, pretesting, consultation with topical experts, and pilot testing (Wingood and DiClemente, 2008).42 Other authors have distinguished between “surface” adaptations, which involve superficial aspects of an intervention, such as activities or materials, and “deep” structural adaptations that relate to content and affect outcomes of interest more directly (Resnicow et al., 2000). Despite this thinking about what is important in adapting programs to meet the needs of diverse communities, a recent meta-analysis of studies of the effects of cultural adaptations on treatment outcomes suggests that results thus far have been mixed (Gonzales, 2017). A prior meta-analysis of ethnic minority children and adolescents who had received an evidence-based intervention showed no difference in outcomes for culturally adapted and nonadapted interventions (Huey and Polo, 2008), while other meta-analyses combining child and adult studies have found that culturally adapted interventions had modestly better effects, particularly for adults compared with children (Benish, Quintana, and Wampold, 2011; Griner and Smith, 2006). And a recent review of parent training interventions found that parents’ ethnicity did not appear to moderate the effects of the interventions, and that cultural adaptation did not appear to improve outcomes compared with nonadapted programs (Ortiz and Del Vecchio, 2013). In their systematic review of four widely disseminated evidence-based parent training interventions, Baumann and colleagues (2015) found only 8 of 610 published studies that met their strict criteria for cultural adaptation; they advocate documenting explicitly how, why, and for whom adaptations were made (see, for example, Chowdhary et al., 2014; Le et al., 2010). These mixed findings suggest that, although surface adaptations may be necessary to ensure that interventions are culturally sensitive to and engage the populations being served, more rigorous research is needed to determine whether deep adaptations are warranted. Some researchers have noted the time and cost of evaluating these adaptations and the resulting potential delay in dissemination of effective treatments to those most in need (Domenech Rodriguez, Baumann, and Schwartz, 2011). Further, it may be best if intervention developers examine broad issues of culture and context in the development process, while gathering input from multiple constituencies. A Focus on Community Engagement                                                              41 In practice, interventions that address MEB health and other objectives are frequently adapted without careful attention to fidelity. For example, in a survey of Pennsylvania program grantees, 44 percent of respondents reported making adaptations to program procedures, dosage, and content, both intentional and not (Moore, Bumbarger, and Cooper, 2013). Reasons cited were primarily logistical in nature: lack of time, limited resources, and difficulty with participant engagement. 42 See also Lau (2006) for discussion of the Selective and Directed Treatment Adaptation Framework, designed for use in determining whether and to what extent adaptation is recommended.   184

Prepublication Copy, Uncorrected Proofs Chapter 8 Research on how to adapt programs effectively to serve diverse populations increasingly highlights the importance of engaging directly with communities. For MEB interventions, one way to accomplish such engagement and to respond directly to community needs is to engage community health workers in delivering the interventions. Such workers are often from the same community as the clients being served, and evidence of the effectiveness of this approach has been found in a variety of settings and for a variety of targeted problems in research conducted both in the United States and in other countries (Barnett et al., 2018). This research has addressed topics ranging from the delivery of a parenting intervention to Native American families to treatment for traumatic stress and mental disorders (Barlow et al., 2015; Chibanda et al., 2016; Murray et al., 2015; Nadkarni et al., 2015; Patel et al., 2016; Walkup et al., 2009). However, such barriers as rules and policies related to reimbursement (e.g., difficulty securing Medicaid payments for some types of interventions) have hampered the use of this approach in the United States. Looking more broadly, multiple studies have shown community partnership and consultation in adaptation and implementation to be an effective approach (Barrera, Castro, and Steiker, 2011; Baumann et al., 2015; Goodkind et al., 2012; Guttmannova et al., 2017). An example of this approach is community-based participatory research (CBPR), which emphasizes reciprocal knowledge exchange and mutual benefit among partners (Minkler and Wallerstein, 2011; Wallerstein and Duran, 2010). A recent meta-analysis of eight programs using this approach found improvements in both health outcomes for individuals and measures of health in the community (Salimi et al., 2012). Another study, in the context of targeting depression, compared the results for a CBPR-based approach with those for standard strategies for delivering depression care. The authors found that the results for some indicators were equivalent but for others were better with the CPBR-based approach (Wells et al., 2013). Positive results have been documented as well for the CBPR approach in child and youth mental health interventions (Betancourt et al., 2015; Mance et al., 2010; Stacciarini et al., 2011). The CBPR approach has shown particularly strong results in programs designed to promote MEB health in Native American populations. Native American youth have long been at particularly high risk for dropping out of high school, substance use disorders, teen pregnancy, and suicide. These high risks have been attributed to multiple factors, including poverty, historical and acute trauma, and lack of access to evidence-based prevention interventions (Brockie et al., 2015; Goodkind, Lanoue, and Milford, 2010; Ohannessian et al., 2015; Thayer et al., 2017; Whitesell et al., 2009). Studies using a CBPR approach to promote mental health among Native American youth have also demonstrated positive effects (Goodkind et al., 2012; Mullany et al., 2012). A study of two interventions for prevention of alcohol abuse among youth in a rural Native American community that were adapted for the local culture—Communities Mobilizing for Change on Alcohol (CMCA), a community organizing intervention, and CONNECT, a school-based universal screening and brief intervention—showed that both effectively decreased individual-level alcohol use and heavy episodic drinking (Komro et al., 2015). The CMCA intervention also had community effects on reducing overall access to alcohol among underage youth (Komro et al., 2017). An alternative to adapting an existing evidence-based intervention is when local practitioners develop interventions based on the real-world needs and cultures of specific communities (Marsiglia and Kulis, 2009). This approach, often referred to as the use of practice- based evidence, highlights culturally specific interventions and healing practices that are used in ethnic minority communities and reflect the beliefs and values of the local community (Isaacs et   185

Prepublication Copy, Uncorrected Proofs Chapter 8 al., 2005). Initiatives developed in this way may be well accepted as effective by the local community. However, one recent examination of interventions in use in a statewide setting showed that few practices, regardless of whether they were based on research or practice-based evidence, were culturally specific (Lyon et al., 2017). Moreover, most of the cultural features noted reflected only surface-level program characteristics, such as providing services in languages other than English or provider–recipient matching, rather than deep content characteristics that attend to cultural values and other central cultural components (Lyon et al., 2017). IMPLEMENTATION STRATEGIES Implementation strategies are those methods and tools used to change policies, administrative procedures, and environments; they are the how of implementation, the means through which core components are put into practice. Such strategies might include, for example, engaging program consumers, providing training and technical support to staff delivering the program, or garnering stakeholder support for the program. The evolution of implementation science has included a focus on identifying, classifying, and studying these basic elements of the implementation process (Proctor, Powell, and McMillen, 2013). This section reviews in turn discrete and blended implementation strategies, providing three examples of the latter, and then examines the evidence on ways of supporting implementation efforts. Discrete Implementation Strategies Some implementation strategies are discrete—single actions or processes (e.g., reminders, educational meetings) that are part of an effort to implement a new practice or program. Researchers have examined discrete strategies and identified an array of purposes they serve, including engaging consumers of the program being implemented, developing relationships with other stakeholders, supporting practitioners, and providing interactive assistance or training (Powell et al., 2015; Waltz et al., 2015). Such actions are the building blocks of more complex strategies, and researchers have analyzed them in seeking to identify core implementation components and track and assess fidelity. Their analyses have also helped support the development of a common language for strategies and highlight those that have not been adequately studied, facilitating efforts to select and tailor strategies for different contexts (Powell et al., 2017). Still, the evidence base on discrete strategies and ways of combining them to form multifaceted strategies remains nascent. Only a handful of strategies have been studied in detail. For example, strategies designed to change the behavior of health care professionals (such as giving them printed materials, conducting audits and providing feedback, and influencing them through local opinion leaders) have demonstrated some effectiveness (Grimshaw et al., 2012). But few strategies have been tested for their individual contributions to effectiveness, and researchers are increasingly turning their attention from questions about whether strategies work to how, why, where, and for whom they work. This research is a useful contribution to the field, but more research is needed to improve understanding of the potential impact of tailoring implementation strategies, the barriers to implementation in particular contexts, and optimal ways of selecting strategies (Baker et al., 2015).   186

Prepublication Copy, Uncorrected Proofs Chapter 8 Blended Implementation Strategies: Three Examples Blended implementation strategies combine several discrete strategies to address broad implementation challenges (Powell et al., 2012; Spoth, Redmond et al., 2013). Those challenges are complex and can include, for instance, increasing local readiness and enhancing program quality (Chinman et al., 2015; Hawkins, Catalano, and Arthur, 2002). This section explores three examples of blended strategies, which have been developed and tested to assist agencies, communities, and states in sustainably implementing MEB health programs: Communities That Care (CTC), Promoting School-Community-University Partnerships to Enhance Resilience (PROSPER), and Getting to Outcomes (GTO). Communities That Care (CTC) CTC is a web-assisted system, first developed in the 1990s, designed to support communities in planning and capacity building aimed at promoting youth development through effective local coalition action. It provides such resources as instructional videos and other materials, research summaries, live training in the use of the materials for community members, and web-based consulting and coaching for communities and states.43 Its focus is on making evidence about prevention available so that communities can promote healthy development and outcomes and reduce problem behaviors in young people. The developers used a CBPR process (see above) to continuously improve the design (which has been tested in 24 randomized controlled trials), and CTC has now been implemented in several hundred communities in the United States (Chilenski et al., 2019; Fagan et al., 2019) and in Europe, South America, and Australia (Fagan et al., 2019; Jonkman et al., 2009; Pérez-Gómez et al., 2016; Toumbourou et al., 2019). Box 8-3 describes CTC’s implementation process. BOX 8-3 Communities That Care’s (CTC’s) Implementation Process Implementation of CTC involves a five-phase process: 1. Get Started: Communities get ready to introduce CTC. They work behind the scenes to:  Activate a small group of catalysts.  Assess how ready the community is to begin the process.  Identify key community leaders to champion the process.  Invite diverse stakeholders to get involved. 2. Get organized: Communities form a board or work within an existing coalition. After recruiting community board members, they:  Learn about prevention science.  Write a vision statement.                                                              43 For more information, see https://www.communitiesthatcare.net.   187

Prepublication Copy, Uncorrected Proofs Chapter 8  Organize workgroups.  Develop a timeline for installing CTC. 3. Develop a community profile: Communities assess community risks and strengths—and identify existing resources. The community board and workgroups:  Review data from the community’s youth survey.  Identify priority risk and protective factors that predict targeted health and behavior problems.  Assess community resources that address these factors.  Identify gaps to be filled in existing resources. 4. Create a community action plan: The community board creates a plan for prevention work in their community to:  Reduce widespread risks and strengthen protection.  Define clear, measurable outcomes using assessment data.  Select and expand tested and effective policies and programs using the Blueprints for Healthy Youth Development website. 5. Implement and Evaluate: In this final phase, communities:  Implement selected programs and policies.  Monitor and evaluate them.  Measure results and track progress to ensure improvements are achieved. SOURCE: Excerpted from https://www.communitiesthatcare.net/how-ctc-works. The central idea of CTC is that the training and technical support it provides serve as a catalyst for the development of a well-functioning community coalition of diverse local stakeholders. This coalition develops the skills needed to assess the highest-priority risk and protective factors in the community, and thus to select effective programs that can address community needs, implement those programs faithfully, and monitor the results (Hawkins, Catalano et al., 2008; Rhew et al., 2013). Reducing targeted risk and strengthening targeted protective factors is expected to lead to lower rates of problem behavior and more favorable behavioral health outcomes for local youth. The CTC process emphasizes community support and collaboration for prevention activities and strengthening of community norms against adolescent drug use, and has defined a social development strategy to protect youth beginning at birth; see Box 8-4 (see also Brown et al., 2014). BOX 8-4 Communities That Care’s (CTC’s) Social Development Strategy [Using] the Social Development Strategy in daily interactions with young people…helps keep them on track for healthy development. The strategy has five key components:   188

Prepublication Copy, Uncorrected Proofs Chapter 8  Opportunities: Provide developmentally appropriate opportunities to young people, for active participation and meaningful interaction with prosocial others.  Skills: Teach young people the skills they need to succeed  Recognition: Provide consistent specific praise and recognition for effort, improvement, and achievement.  Bonding: Acknowledge a young person’s effort and promote positive bonding —a sense of attachment, emotional connection and commitment to the people and groups who provide that recognition. Bonding can occur with a family member, teacher, coach, employer, or neighbor.  Clear Standards for Behavior: Through the process of bonding, young people become motivated to live according to the healthy standards of the person or group to whom they are bonded. SOURCE: Excerpted from https://www.communitiesthatcare.net/how-ctc-works/social- development-strategy. CTC has been evaluated in both quasi-experimental (Chilenski et al., 2019; Feinberg et al., 2007, 2010) and experimental studies (Brown et al., 2014; Hawkins, Catalano et al., 2008; Oesterle et al., 2018). These studies have provided strong support for CTC’s theory of change and its impacts on positive youth development. Among the effects that have been documented are improved coalition functioning (Shapiro, Hawkins, and Oesterle, 2015; Shapiro, Oesterle, and Hawkins, 2015); sustained improvements in the adoption of a science-based approach to prevention (Gloppen et al., 2012; Gloppen et al., 2016); implementation of a greater number of effective programs relative to control communities (Fagan et al., 2011, 2012); high levels of fidelity to the program and CTC prevention system (Arthur et al., 2010; Fagan et al., 2009; Quinby et al., 2008); and improvements in risk and protection in middle school (Hawkins, Brown et al., 2008; Kim et al., 2015). Researchers have also generally documented sustained reductions in health risk behaviors among study participants, including reductions in the prevalence of current substance use, delinquency, and violence through grade 10 (Hawkins et al., 2009), and greater abstinence from gateway use of drugs and antisocial behavior and lower incidence of violence through age 21 (Feinberg et al., 2010; Oesterle et al., 2018). A quasi-experimental trial across Pennsylvania school districts that implemented CTC showed small to moderate improvements in delinquency compared with students from non-CTC districts (Feinberg et al., 2010) and long-term (16-year) sustained reductions in substance use after statewide adoption of the program (Chilenski et al., 2019). Research to refine understanding of how the elements of the program function in different contexts is ongoing. Promoting School-Community-University Partnerships to Enhance Resilience (PROSPER) PROSPER is a system for linking university researchers with state and community teams to support the delivery of effective programs for preventing risky behaviors, promoting youth development, and strengthening families.44 Its focus is on taking advantage of existing public education infrastructure as a foundation for building the capacity needed to implement and                                                              44 For more information, see http://helpingkidsprosper.org (see also Spoth et al., 2004; Welsh et al., 2016).   189

Prepublication Copy, Uncorrected Proofs Chapter 8 sustain effective programs, engaging teams that understand local concerns and culture. PROSPER provides technical assistance so that programs are delivered as intended, as well as supported and sustained by the community. In the PROSPER model, extension agents from land grant universities serve as prevention coordinators on local community prevention teams. Representatives from public schools co-lead the teams, and a state management team consisting of university officials and prevention researchers provides oversight and supports evaluation activities. PROSPER’s National Network supports the partnership by providing training and ongoing technical assistance and coaching, as well as the expertise in prevention science of university-based prevention researchers. The extension agent offers community knowledge and experience in disseminating educational programs, while the public school offers access to youth and educators in the community. PROSPER builds on this initial partnership by adding other community providers of services to youth and families to form small strategic teams. Once a strategic team has been formed, its members select one family-based and one school-based prevention program from a menu of evidence-based programs PROSPER has identified (an approach that contrasts with that of CTC, which gives communities more latitude in selecting programs). Team participants complete a three-unit training program (see Box 8-5). Program area specialists, prevention scientists, and evaluation experts support teams throughout the implementation process. PROSPER’s National Network further supports partnership by providing training and ongoing technical assistance, as well as expertise in prevention science (Partnerships in Prevention Science Institute, 2019). BOX 8-5 PROSPER’s Training Program All PROSPER trainings can be tailored to meet the needs of each partnership team, but generally include core content divided into three units:  Unit 1 occurs in the first year of the partnership, and focuses on initial organization and definition of participant roles. During this training, participants develop a long- term plan for full implementation.  Unit 2 also occurs in the first year. It builds on the first training by teaching participants about selecting and implementing a family-focused program.  Unit 3 takes place in year 2, and focuses on the selection and implementation of the school-based program. SOURCE: Adapted from https://prosper-ppsi.sws.iastate.edu/how-it-works/state-partnership- training?_ga=2.224854418.964852718.1553619796-683765434.1551211193 (Partnerships in Prevention Science Institute, 2019). PROSPER has been evaluated in a number of studies, including a longitudinal cluster- randomized trial that began in 2002 (Redmond et al., 2009; Spoth and Greenberg, 2011; Spoth, Clair et al., 2007; Spoth, Redmond et al., 2007; Spoth, Trudeau et al., 2013; Spoth et al., 2015). Among the program’s documented benefits are small to moderate increases in rates of family recruitment in prevention programs; improvement in child and family risk and protective factors that predict adolescent substance use; reduced rates of prescription drug and opioid misuse; and   190

Prepublication Copy, Uncorrected Proofs Chapter 8 reductions in youth misconduct, such as stealing, skipping school, and carrying a weapon (Spoth et al., 2015). Implementation studies of PROSPER have documented the role of poverty, attitudes about prevention, substance use norms, and prior experience with collaboration in predicting team functioning (Feinberg et al., 2007; Greenberg et al., 2007). These studies have also showed that providing technical assistance to a community team was associated with improved team functioning (Chilenski et al., 2016). Additionally, teams that functioned well early on were better able to address challenges related to long-term sustainability (Perkins et al., 2011). Teams also demonstrated multiple pathways to financial viability, with some communities generating more in external resources and others more in in-kind contributions (Welsh et al., 2016). Getting to Outcomes (GTO) GTO is a toolkit developed by researchers to help communities implement and evaluate programs that target risk behaviors in young people and, like CTC and PROSPER, is designed to link research on implementation with practice in communities.45 Rather than identifying programs that researchers recommend to communities, GTO offers supports to community leaders in following 10 steps (see Box 8-6) to identify the best program for meeting the community’s needs and adapt and implement that program effectively to achieve the desired results. Steps 1 through 6 are planning activities, steps 7 and 8 detail implementation processes and evaluation, and steps 9 and 10 focus on the use of data to improve and maintain programs. BOX 8-6 Getting to Outcome’s (GTO’s) 10 Steps 1. Focus Choose which problem(s) to focus on 2. Target Identify goals, target population, and desired outcomes 3. Adopt Find existing programs and best practices worth adapting 4. Adapt Modify the program or best practices to fit your needs 5. Resources Assess capacity (staff, financing, etc.) to implement the program 6. Plan Make a plan for getting started: who, what, when, where, and how 7. Monitor Track planning and implementation. How did it go? 8. Evaluation Evaluate the program’s success in achieving desired results 9. Improve Make a plan for continuous quality improvement 10. Sustain Consider how to keep the program going if it is successful SOURCE: Excerpted from https://www.rand.org/health-care/projects/getting-to-outcomes.html (RAND Corporation, 2019). GTO is both a model and a support intervention. The 10 steps are intended to serve as a guide for communities in identifying and implementing prevention programs on their own. Unlike PROSPER and CTC, which emphasize reliance on evidence in the selection of programs, GTO is intended to strengthen agencies’ and organizations’ use of prevention programs                                                              45 For more information, see https://www.rand.org/health-care/projects/getting-to-outcomes.html (see Chinman, Imm, and Wandersman, 2004; also Chinman et al., 2018).   191

Prepublication Copy, Uncorrected Proofs Chapter 8 regardless of prior evidence of effectiveness. GTO also provides support, including manuals, in- person training, and onsite technical assistance (Wandersman, Chien, and Katz, 2012; Wandersman et al., 2016), designed to build practitioners’ knowledge and strengthen their skills in such areas as goal setting, planning, and evaluation. This increased capacity, in turn, is expected to improve the fidelity of the selected prevention program and increase the likelihood that desired prevention outcomes will be achieved (Chinman et al., 2016). GTO has been tested in a number of studies, including those with both quasi- experimental and randomized designs. In a recent cluster-randomized trial, researchers documented improvements in process outcomes and in youth attitudes related to sexual risk behaviors, such as intentions with respect to condom use (Acosta et al., 2013; Chinman et al., 2009); however, youth behaviors, such as frequency of sex and condom use, did not change (Chinman et al., 2018). Evidence about Implementation Support External providers of implementation support work directly within organizational and system environments to ensure the success and sustainability of program implementation and scale-up. Implementation support is sometimes provided by the technology-transfer companies established to disseminate well-established programs, although it is most commonly a function of intermediary organizations established to support the implementation or scale-up of a number of effective programs within a region or state (Franks and Bory, 2015; McWilliam et al., 2016; Mettrick et al., 2015). Such support may be paid for by program adaptors, but is more commonly paid for by program funders (e.g., state and federal service administrators, private foundations) to support their investments and increase the likelihood of success. The three examples described above illustrate how implementation support may enhance the capacity of agencies, coalitions, and communities to carry out prevention programming. Each of these blended implementation strategies includes the provision of external support in the form of training and technical assistance for facilitators, as well as change agents. This type of support is found in most implementation frameworks; it is generally both proactive and responsive in nature and usually involves a combination of implementation science and skills training, facilitation, and supportive behavioral coaching for individuals, groups, and organizations (Meyers, Durlak, and Wandersman, 2012). Other work has clearly indicated that external support plays a primary role in optimizing local implementation outcomes (Berta et al., 2015; Blasé, 2009; Chinman et al., 2016; Katz and Wandersman, 2016; Rushovich et al., 2015; Spoth and Greenberg, 2011; West et al., 2012). Studies of the PROSPER model, for example, showed that collaboration with providers of technical assistance (e.g., cooperation, responsiveness) was associated with the achievement of local implementation goals, such as higher participant recruitment rates, and stronger functioning of community prevention teams (Chilenski et al., 2016; Spoth, Clair et al., 2007). The provision of external support early in local implementation processes demonstrated particular benefits in studies of CTC and GTO (Chinman et al., 2016; Feinberg, Ridenour, and Greenberg, 2008). Similar work in other contexts reinforces these findings (Fagan and Mihalic, 2003; Leeman et al., 2015; Romney, Israel, and Zlatevski, 2014; West et al., 2012), although research to determine the necessary dosage of implementation support has thus far been indeterminate (Beam et al., 2012; Chinman et al., 2016; Feinberg, Ridenour, and Greenberg, 2008; Spoth, Clair et al., 2007).   192

Prepublication Copy, Uncorrected Proofs Chapter 8 SUMMARY Research conducted in the past decade has shed additional light on aspects of implementation that are key foundations for successful scale-up of effective approaches. Conclusion 8-1: The effectiveness of an intervention intended to foster healthy MEB development depends on careful research that identifies the intervention’s core theoretical components that are essential to its effectiveness and how those components influence long-term outcomes. While a variety of methods for assessing core components have been developed, they have not been routinely applied in trials, and more work is needed to develop means of distinguishing essential from nonessential components. Conclusion 8-2: Adapting nonessential elements of a program so that it meets the needs of diverse communities while retaining the program’s core components is key to successful implementation. While more research is needed to develop methods of identifying specific adaptations that yield improved outcomes, strong evidence indicates that engaging communities closely in the selection and implementation of promotion and prevention programs is critical to program success. Conclusion 8-3: The evidence base on discrete implementation strategies and ways of combining them remains nascent. A handful of discrete strategies have been studied in detail, but research is needed to improve understanding of optimal ways of selecting such strategies and the potential impact of tailoring them to address the barriers to their implementation in particular contexts. Conclusion 8-4: Evidence indicates that blended implementation strategies that involve external support to practitioners in such forms as providing training, technical assistance, or facilitators play a key role in in optimizing local implementation outcomes.   193

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Healthy mental, emotional, and behavioral (MEB) development is a critical foundation for a productive adulthood. Much is known about strategies to support families and communities in strengthening the MEB development of children and youth, by promoting healthy development and also by preventing and mitigating disorder, so that young people reach adulthood ready to thrive and contribute to society. Over the last decade, a growing body of research has significantly strengthened understanding of healthy MEB development and the factors that influence it, as well as how it can be fostered. Yet, the United States has not taken full advantage of this growing knowledge base. Ten years later, the nation still is not effectively mitigating risks for poor MEB health outcomes; these risks remain prevalent, and available data show no significant reductions in their prevalence.

Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda examines the gap between current research and achievable national goals for the next ten years. This report identifies the complexities of childhood influences and highlights the need for a tailored approach when implementing new policies and practices. This report provides a framework for a cohesive, multidisciplinary national approach to improving MEB health.

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