Publication

Overview

emcfScaling up evidence-based programs is not easy, and it is something that program developers and distributors approach in many different ways. This brief reviews the best practices for scale up of effective programs from across the literature and describes the experiences of several effective programs that are at varying levels of scale across the country and internationally.

Key Findings

  • Effective replication and scale-up of an evidence-based program is a process that requires time, planning, and the mobilization of effort and resources from communities, program developers, and implementing organizations.
  • Program developers and implementing organizations take many approaches to scale-up, with some providing the infrastructure to support high-quality implementation through a central organization (e.g., a program purveyor) and others making program materials and training available for purchase for any interested implementer.
  • To ensure that scale-up efforts result in high-quality implementation, program developers, implementing organizations, and funders should consider a number of factors, including identification of core components, selection of the appropriate program for the local context, organizational capacity for scale up, staff and leadership buy-in, monitoring of fidelity and outcomes, provision of ongoing training and technical assistance, and identification of sustainable funding.

Background

In recent years, the number of intervention approaches with rigorous evidence of effectiveness has grown rapidly. Several Federal and foundation funding streams have specifically targeted rigorous evaluations, such as the U.S. Department of Education’s Investing in Innovation Fund (i3), the U.S. Health and Human Services Administration-funded Teen Pregnancy Prevention Program (TPP), the Social Innovation Fund (SIF, a program of   the Corporation for National and Community Service), the Edna McConnell Clark Foundation, and the Annie E. Casey Foundation. Although many interventions have modest impacts, it is nevertheless the case that a major increase in the availability of effective programs can improve the outcomes of children, youth, and families. Importantly, the substitution of effective programs for ineffective programs could have a substantial net positive effect, especially when large numbers of children and youth are served.

At the same time, the task of scaling-up evidence-based programs is very challenging. Developers or purveyors of effective programs are not always well equipped or funded to deliver programs on a wide scale with quality. There is a growing body of research that describes what is needed and what it takes to successfully scale up a program (i.e., to expand a program while retaining its effectiveness) and what a successfully-scaled program looks like.

This brief describes the best practices for scaling-up evidence-based programs, gathered from across the research literature and from the experiences of organizations operating evidence-based programs. Child Trends identified 73 programs with demonstrated impacts on at least one outcome related to delinquency, high school dropout, or unintended pregnancy, and interviewed staff (e.g., developers, program executives, or purveyors) from 20 of those programs to gain insight into their ability to scale up their program effectively. We use the experiences described by these program operators to illustrate the best practices and common challenges related to implementation, replication, and scale-up found in the literature.

The term “scaling-up” has been used to refer to the replication of a program in a new area or with a new population, the adaptation of a program for a new context, the expansion of a program to a larger number of sites, or expanding the capacity of existing implementation sites to serve a larger number of people. In this brief, we take a broad view of scale-up to include all of these definitions; however, the essential element of “successful” scale-up is that the effectiveness of a program is maintained.

As has been noted by many who study the replication of evidence-based programs, there is no single path from program development to scale-up. Accordingly, the infrastructure that supports program implementation varies widely (Supplee & Metz, 2015). In our research, we have encountered several common types of organizational structures, including:

  • a centralized organization that connects communities to a menu of evidence-based interventions and supports program implementation in the community;
  • a centralized organization that supports replication of a single program with certification and/or licensing of program implementers that has full oversight of implementation and fidelity;
  • a centralized organization that supports replication of a single program with some level of certification and/or training required for program implementers, with limited oversight of fidelity and implementation;
  • a research and/or practitioner-developed curriculum being sold by a purveyor that provides varying levels of training, technical assistance (TA), and support; and
  • a research and/or practitioner-developed curriculum being sold or provided by the developer who typically provides limited training or TA and little implementation oversight.

What is Needed for Effective Scale-Up of Evidence-Based Interventions?

Evidence of impact

A successful evaluation provides a degree of certainty that the program in question has made positive impacts on one outcome of interest at least once. In reality, not all programs that have been scaled- up have formal evidence of effectiveness; however, we view this as a fundamental prerequisite for replication for several reasons. The key reason is to ensure that the program is doing no harm to its participants and is, in fact, helping them. Second, it helps legitimize the program in the eyes of many outsiders, and opens the door to discussions about replication and scale. To stakeholders, the existence of a formal evaluation and the documentation of positive impacts assuages fears about the potential pitfalls of implementing a new program – namely, wasting resources on an initiative that creates no change or that may have unintended negative effects. Finally, evaluation provides information about what implementation components are necessary for the program to be replicated with a high degree of quality. Materials and infrastructure developed in the process of building an evidence base, such as fidelity monitoring tools or training curricula, can also be put to use as a program is replicated.

Written program materials and a documented program structure

Before a program can be replicated, there must be written materials for implementers to follow. These could include written curricula with lesson plans, timelines, training materials, performance management measures, and/or activities guides. Having a defined and documented structure for a program allows fidelity assessments to be carried out, and can facilitate scale-up by allowing certain aspects of the program to be mass produced. Because they provide an objective frame of reference for what the program is, formalized, written program materials allow for the assessment of drift from the program model and are an essential part of program replication.

Core components and theory of change or logic model

Having clearly defined core components is instrumental to successful scale-up. In much of the literature, the definition of program implementation boils down to conducting a set of activities that drive program impacts, often called core components (Bradach, 2003; Office of the Assistant Secretary for Planning and Evaluation [ASPE], 2013a; Moore, 2009) and implementation fidelity is sometimes measured by what percentage of a program’s core components was implemented (ASPE, 2013a; Elliot & Mihalic, 2004). Program developers may identify their core components as part of a logic model or theory of change, but sometimes program components are named as core or required without linking back to these frameworks. Presently, there is little formal research used in the process of identifying programs’ core components (ASPE, 2013a; Spoth et al., 2013; Supplee & Metz, 2015).

Core components are useful not only in guiding which aspects of a program must be implemented, but also in providing guidance on which aspects can be adapted. Given the importance of ensuring that programs are well suited to the specific implementation context – particularly to the intended target audience (which we discuss further in the following sections) — adaptability can be seen as a valuable quality in a program. One forum of researchers and practitioners concluded that “no tension exists between [fidelity and adaptation], but that each is critically important to successful replication” (ASPE, 2013b). By stating what cannot be changed, core components tacitly allow for modifications or adaptations of other program components (Moore, 2009).

We encountered many programs that are being replicated or scaled-up without having clearly defined core components, and even more that have core components that were not identified through research. Rigorous methods for empirically validating core components, such as random assignment studies evaluating individual core components, are rarely practical (Gottfredson et al., 2015), and other proposed methods such as usability testing (ASPE, 2013a) still take time, money, and manpower that many program developers lack.

What is Needed for Effective Scale-Up of Evidence-Based Interventions?

Planning for scale-up

Effective, quality scale-up does not happen by chance; it takes time, and is the result of careful planning in advance of implementation. Even once a new location or population has been identified to receive an evidence-based program, many months or even years of preparation and planning may be needed before a single program participant is served. For example, in the Quality Implementation Framework developed by Meyers, Durlak, and Wandersman (2012), ten of the 14 critical steps occur prior to implementation of a program. In their review of the implementation of model programs that were part of the initial Blueprints for Violence Prevention—Replication Initiative, Elliott and Mihalic (2004) identified sites’ lack of readiness and preparation as the source of many replication failures. It often took six to nine months of technical assistance and training for a site to be ready to begin implementing a program (Elliott & Mihalic, 2004). Time spent planning for an initial implementation, such as thinking through the factors that will support or inhibit quality implementation, will help ensure a smoother and more successful scale-up down the line (VanLandeghem, 2011).

Needs assessment in the local context

An important part of planning for scale-up is to assess the local context in which a program is to be implemented. Just as communities differ in the demographic makeup of their residents, they also differ in the array of local risk and protective factors and needs, and the potential organizational or structural barriers to successful implementation and sustainability. Needs assessments and fit assessments are valuable tools for communities looking for a program to fix a perceived problem and for programs seeking to scale up (Management Systems International, 2012; Metz, Naoom, Halle, and Bartley, 2015). A needs assessment helps ensure that the impacts of a program and the needs of a community line up appropriately (Supplee & Metz, 2015). A fit assessment examines the organizational and community context for a potential program in order to ensure that high-quality implementation is feasible (Supplee & Metz, 2015). From the perspective of a program and its funder(s), a needs assessment means examining what communities and populations could benefit from the proven impacts of a specific program. On the other hand, a needs assessment can be undertaken by the community itself or another local entity, where the process begins first by assessing local needs, followed by the selection of an appropriate evidence-based program based on the findings. Community leaders can use local data on problem behaviors and risk and protective factors to determine what problems need to be addressed and choose evidence-based interventions (Spoth et al., 2013). For example, prior to selection of an evidence-based intervention, the Communities that Care (CTC)[1] prevention system delivers an in-school survey and leverages archival data to assess the unique needs of the community – in fact, using epidemiological data is a core component of CTC (Jonkman et al., 2009).

Assessing need is not necessarily a one-time occurrence, just as youth development services are not a “one-shot” event, but an investment that takes time (Moore, 2009). Accordingly, communities and implementing organizations need to continually monitor the needs of the community, particularly as previously-identified needs are addressed. An initial needs assessment provides the baseline data against which later outcomes can be compared (Chinman, Imm, & Wandersman, 2004). In this way, needs assessments not only support early decision-making, but also function as a performance management tool informing subsequent quality improvement efforts. The Quality Implementation Framework developed by Meyers et al. (2012) places conducting a needs and resources assessment in the first phase of each implementation cycle. Thus, every iteration of program implementation begins, in theory, by determining the community needs and its present capacity to support implementation. CTC administers the CTC Youth Survey biannually after beginning an intervention to inform a continuous decision-making process around intervention (Jonkman et al., 2009).

Local context can also influence the way a program is implemented, so it can be beneficial to carry out a fit assessment of local factors that may influence successful program implementation (Gottfredson et al., 2015; Metz et al., 2015; Supplee & Metz, 2015). These examinations may consider a multitude of factors such as local policies, infrastructure, or participant characteristics, and assess intervention models for feasibility and appropriateness based on these factors. A community’s capacity to implement a program and the fit of the program for the community are equally important for ensuring successful scale up. Halgunseth et al. (2012) examined the factors associated with different levels of implementation fidelity for the Good Behavior Game (GBG) and found that when both communities and organizations had high levels of capacity, implementers used more GBG strategies and implemented them with greater fidelity than implementers with a high level of either organizational or community capacity.

Although ongoing need and fit assessments are ideal, they can be expensive and time-consuming. Program implementers or community members often rely on their experience on the ground and their understanding or perception of the needs of their community in lieu of conducting a formal assessment. This could result in selection of a program for which a) high-quality implementation in the local context is not feasible, b) demonstrated impacts and community needs are misaligned, or c) both. For example, we reviewed many teen pregnancy prevention programs that are currently being widely replicated. It seems that many are sold by developers or purveyors without discussion with the implementer about the intended community, putting the responsibility on the purchaser to have assessed the need for and fit of the program. The program descriptions typically only state limited information about the context in which they should be implemented for effectiveness (such as a program describing its target population as “adolescents in an urban area”) and often lack detailed information about the infrastructure needed to replicate the program faithfully. Some implementing organizations have expressed “buyer’s remorse” after having selected an evidence-based program with limited information (Stid, Neuhoff, Burkhauser, & Seeman, 2013).

[1] CTC and PROSPER are two prevention systems that provide support and technical assistance to communities looking to improve outcomes for youth. Both are based on helping communities select and implement an evidence-based program that will address their specific needs. PROSPER has been implemented in multiple states in the United States, and CTC has been implemented domestically and internationally. We frequently refer to these two systems as examples of successful models for scale-up and replication.

What is Needed for Effective Scale-Up of Evidence-Based Interventions?

Sufficient organizational capacity

To achieve intended outcomes identified through the needs assessment, it is crucial that organizations have sufficient capacity to implement programs with quality and fidelity. However, high-quality program implementation can be a demanding endeavor for the organization delivering it. Meeting demands at both the individual staff person level (such as having sufficient training) and at the organizational level (such as having adequate staff or infrastructure for fidelity monitoring) is a requirement for implementation to be successful (Metz et al., 2015). However, resource needs are not always clearly defined or delineated, and organizations do not always assess their own capacity to implement before adopting a program.

Program developers have the responsibility of making clear what is needed for program delivery, and when designing programs should keep in mind common barriers or challenges that implementers face (Supplee & Metz, 2015). For example, in our interview with the developers of a positive youth development and problem behavior prevention program, the developers recognized that facilitators did not always have enough time allotted to deliver all of the lessons in the curriculum. Because the program has been identified as “dose-response” – impacts grow as exposure to the curriculum increases – this indicates that improvements in outcomes resulting from its implementation may not be as large as they could have been had the full program been delivered.

Developers and researchers can also conduct original research or use assessment tools to identify potential barriers or facilitating factors for program implementation (Gottfredson et al., 2015). When program requirements are clear, capacity assessments can be used to evaluate potential program providers; Meyers et al. (2012) place organizational capacity assessments early on in their Quality Implementation Framework and consider conducting them a critical step, emphasizing that greater organizational capacity  is related to an organization’s ability to carry out duties such as establishing partnerships and ensuring effective inter- and intra-organizational communication, which indirectly support program implementation. Community partners that have knowledge of the resources available to local implementing organizations can also work to anticipate capacity building needs (Spoth et al., 2013). Together, these multiple perspectives on organizational capacity – the developer-side and the implementer-side – demonstrate the importance of ensuring that high-quality program implementation capacity is established before scale-up takes place.

Leadership and staff buy-in

Successful program replication is not possible without the involvement and buy-in of organizational leadership. Leaders need to establish goals and develop clear and realistic plans regarding development, implementation, and evaluation that enable an organization or program to expand thoughtfully and strategically (Marek, 2011). Leaders can also help garner critical political and community support for a program that lays the foundation for sustainable replication (ASPE, 2013b).

However, organizational leaders cannot ensure successful scale-up of a program on their own. Buy-in from senior staff is essential, but quality replication and sustainable growth is only possible with the involvement of staff at every level of implementation. Staff need to be committed to a program’s goals and be part of important program decisions (Marek, 2011). Several implementation frameworks, including the framework developed by Metz et al. (2015), recommend the use of implementation teams – groups of people who are responsible for the intentional monitoring and support of implementation. These staff should be well versed in an intervention’s core components, understand the infrastructure needed to support and sustain implementation, be committed to the use of data for feedback, and build collaboration across stakeholders (Metz et al. 2015). Among the programs we spoke with, implementation teams were most often used by centralized organizations with a high degree of oversight of program replication. For example, one widely replicated therapeutic intervention for families of high-risk young people, particularly those in the juvenile justice system, is disseminated by a for-profit company that uses a small staff of experts and coaches who work with a few sites to assist with implementation.

If a program is being replicated at multiple sites, community leaders in every location should also be involved. This helps ensure that local leaders are invested in the success of a program and may ultimately become advocates for its continued presence in a community (Browne, 2014; Meyers et al., 2012). We spoke with several organizations that make community buy-in a key component of the selection of new sites and ongoing implementation, but this is a particularly important feature for program models that include community-driven components. The Communities in Schools high school dropout prevention program uses a federated model in which regional directors in the national office work with state offices, who in turn work with local affiliates that are accredited by the national office to ensure that they are delivering the core model with fidelity and quality. The PROSPER program (a prevention system that provides support and technical assistance to communities) uses Community Teams that are responsible for sustaining high-quality program delivery, to involve local stakeholders such as school administrators or social service providers as well as representatives from law enforcement, faith-based institutions, or other interested organizations.

Creating a strong network of leaders can be difficult even for a well-developed program that has community leadership built into its model. For example, during the initial phases of developing a new site, CTC creates community boards that are responsible for selecting the specific interventions to be implemented locally. However, one evaluation of CTC suggested that new sites often spent a great deal of time and energy clarifying roles and addressing these issues in the process of formalizing partnerships with other organizations when trainings did not provide technology for boards to best collaborate with potential partner organizations in the community (Jonkman et al., 2009).

Getting non-leadership staff buy-in can also be challenging. Experienced facilitators may want to be creative and not necessarily implement a program exactly as written (Stid et al., 2013). Experienced staff who have worked with other youth-serving programs can be very attached to programs they have seen be effective in the past. The transition to another program, model, or curriculum can be difficult and require strong leadership (Management Systems International, 2012). Adequately training all staff can be helpful in avoiding some of these challenges, but staff buy-in is an ongoing issue for many organizations.

What is Needed for Effective Scale-Up of Evidence-Based Interventions?

Monitoring of outcomes and fidelity data

The importance of regular monitoring of data – particularly data on implementation fidelity and/or participant outcomes – to facilitate continuous quality improvement efforts is often cited in the implementation and scale-up literature.[2]

Outcomes measurement can provide valuable insight into whether or not a program is effective when implemented at scale and these data can be used internally for continual program improvement. Outcomes evaluation is a core component of successfully scaled models like CTC and PROSPER (Jonkman et al., 2009; Spoth & Greenberg, 2011). When a program is delivered in new and diverse situations – even with fidelity – one cannot assume that results will be on par with those seen in previous trials (Gottfredson et al., 2015). In their recommendations related to national scale-up of chronic disease prevention initiatives, Hussein and Kerrissey (2013) state that, “[i]t is also critical that outcomes are measured to ensure that the network can produce results comparable to those reached in the clinic.” Outcomes data may come from administrative sources (Supplee & Metz, 2015) or formal evaluations (Marek, 2011; Rosenberg & Westmoreland, 2010).

Fidelity monitoring allows practitioners and researchers to look into the extent to which the program is being implemented as intended when scaled-up. Both CTC and PROSPER have a formal infrastructure for fidelity assessment and the research surrounding the programs emphasizes the importance of this infrastructure in assessing implementation progress, supporting continuous quality improvement, and ensuring positive outcomes (Jonkman et al., 2009; Spoth & Greenberg, 2011). Given that high-quality implementation is an important factor in achieving positive program impacts (Durlak, 2013), fidelity monitoring can serve as a diagnostic or warning tool for implementers. In a quality implementation frameworks that operate in a cycle, such as those suggested by Metz et al. (2015) and Meyers et al. (2012), fidelity and outcomes monitoring dovetail to identify specific programmatic improvements for future implementation.

Fidelity and outcomes monitoring are an extension of other best practices conducted during the planning phase of scale up – the development of core components and ongoing needs assessments. As noted, fidelity measurement is often quantified as the number of core components that are implemented (Elliot & Mahalic, 2004). When a community or a program conducts a needs assessment, it identifies the areas of need – the key outcomes – to be tracked and monitored once the program is up and running. Needs assessment and outcome monitoring continue to go hand-in-hand throughout the scale-up process, in that communities or organizations can  prioritize new outcomes through needs assessment, if previous targets are found to have been effectively addressed through the ongoing monitoring of outcomes (Jonkman et al., 2009; Meyers et al., 2012).

The infrastructure supporting fidelity and outcomes monitoring varied greatly among the programs we talked to. Programs with curricula that are available for purchase often package program materials with tools to collect outcomes or fidelity data – such as practitioner checklists or pre- and post-test surveys – but the use of these tools is left to the discretion of the implementer. Some funders stipulate that implementers collect fidelity and/or outcomes data, but this is not universal. Several programs we spoke with followed implementation models that require oversight of fidelity by a central organization, where training, technical assistance, and monitoring services are packaged with the program curriculum. Some also require practitioners and implementing organizations to go through a certification process. For example, the residential treatment program Treatment Foster Care Oregon (formerly Multidimensional Treatment Foster Care) requires certification from the central program authority (TFC Consultants) or the program developers, and has daily and weekly check-ins with parents and providers to continually monitor progress. While this type of model can support strong implementation fidelity, it also puts greater demands (e.g., manpower and funding) on the central organization. Many programs we spoke with stated that monitoring services were a challenge, and expressed that a lack of resources limited either the scope of their monitoring or the scale of their program (while maintaining a high level of monitoring services). If these costs are built into a program package and therefore the responsibility of the implementing organization, central organizations may find that demand for their program is lower compared with programs using less expensive, more hands-off approaches.

Monitoring of fidelity and outcomes are often seen as expendable activities in situations where funding is being reduced and resources have to be diverted to basic support of programming; for example, a national gang and violence prevention program we interviewed had to cease fidelity monitoring activities when its funding was cut. Unfortunately, insufficient funding for data monitoring may lead to lower quality implementation, which can have several long-lasting consequences. Mediocre execution of programming may have lasting impacts on the documented “effectiveness” of an evidence-based program. Furthermore, if practices are not sustained, future financial investments often become less certain, as funders come to see the program as ineffective or undesirable. Finally, in the most extreme case, services may be disrupted or no longer available for children and families.

[2] See, for example, George et al. (2008), Gottfredson et al. (2015), Metz et al., (2015), Spoth et al. (2013), and Supplee and Metz (2015).

What is Needed for Effective Scale-Up of Evidence-Based Interventions?

Training and technical assistance

Frontline and other program staff cannot implement a program with fidelity if they have not been adequately trained prior to starting a program and don’t have access to ongoing technical assistance throughout implementation (Gottfredson et al., 2015; Spoth et al., 2013). Sufficient training equips staff to deliver an intervention’s core components with a high degree of quality and fidelity to the model (ASPE, 2013a). Training should cover the practical considerations of implementing a program (e.g., the curriculum), how to monitor program activities (i.e., training on fidelity tools), and the theory behind the program (i.e., the theory of change and logic model; Doll, Pfohl, & Yoon, 2010; Spoth et al., 2013).

Coaching, supervision, assessment, and feedback are all important components of ongoing technical assistance (George et al., 2008), and should be delivered proactively by the training provider, as implementation staff may not seek it out (Elliott & Mahalic, 2004). Training and technical assistance providers might be the original program developers, internal staff knowledgeable in the program model, or external consultants who act as master trainers (sometimes referred to as purveyors; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). One evaluation found that a train-the-trainers approach to implementation of the Parent Management Training – Oregon Model intervention was able to sustain implementation fidelity in the third generation of practitioners (Forgatch & DeGarmo, 2011).

We spoke with numerous organizations that offer extensive training to implementers, delivered either by the program developer or by trained coaches. Many organizations are supported by the fees they charge for trainings. Training varies from one-day remote learning modules to multi-component certification processes. However, the availability of training and technical assistance services does not necessarily mean all implementing organizations will take advantage of them, particularly when the services come at an additional fee and are not required for certification or accreditation to implement a program. We also spoke with several organizations or program developers who provide informal training and/or technical assistance upon request, but that don’t require any pre-implementation training.

Having sufficiently trained staff is a common obstacle in every stage of implementation and scale-up, regardless of the program model. The most common (and consequential) training challenges are staff not attending trainings and staff turnover. Rescheduling training sessions, recruiting additional staff, and providing coverage when staff turnover occurs can be very problematic at the site level and have serious implications for quality of program implementation (ASPE, 2013b).

It should be noted that, even before training, purposeful staff selection is important and it is critical that organizations have a clear understanding of what skills, education, and experience make an implementer effective (Bradach, 2003; Elliott & Mahalic, 2004). The programs we spoke with varied in the level of specificity around staff qualifications, from listing specific degrees that facilitators must have, to leaving it up to the implementing agency to select the best staff.

Funding

The importance of identifying funding streams prior to implementing a program is frequently emphasized in the literature (Bradach, 2013; Moore, 2009). To sustain a program, resources should be in place for both present and future programming (at least two years out), and there should be plans in place for additional funding. Funding for each phase leading up to scale-up needs to be considered. This includes: needs assessments and/or program development, meetings with key stakeholders, hiring and training of qualified staff, acquiring program space and necessary materials and technology, and fidelity and outcomes monitoring and coaching. It is important to secure funding streams that support not only the delivery of the core components of a program, but for all the supporting activities that make scale-up successful (e.g., funding for training, coaching, fidelity monitoring, and outcome measurement). This includes thoughtful planning for start-up activities, direct service costs and supports, and infrastructure costs necessary to achieve outcomes.

For national networks looking to scale-up public health interventions, insurance reimbursement may be a good source of funding. This includes private insurance companies, Medicare, Medicaid, and some large self-insured employers like Wal-Mart Stores (Hussein & Kerrissey, 2013). While they are not always an option for programs, consistent and stable sources of internal funding or an endowment improve sustainability (Management Systems International, 2012). Some organizations use their growth capital to increase their capacity to communicate program effectiveness (and cost-effectiveness) in order to attract more sustainable funding going forward (Ryan & Taylor, 2012). In some cases, programs may want to use a “braided” funding approach, meaning having multiple sources of funding that each go to a specific purpose. For example, one stream may fund implementation needs, and another may fund data collection initiatives (Spoth et al., 2013).

The consequences of limited funding can also be seen at every level of development from implementation to replication. At the most basic level, inadequate funding means programs will only be available to a limited number of children and families. In the long term, inadequate funding makes it difficult to sustain a program, which will undoubtedly have implications for the magnitude of impact a program can achieve.

Yet, funding is one of the most prevalent obstacles that organizations face at every stage of implementation, from program development to replication and scale-up. Some even say funding is the biggest limiting factor for program scale-up (Browne, 2014). The struggle to secure adequate resources is partially a result of the way funding structures operate. There are many reasons for limited investment in evidence-based prevention programs, ranging from a lack of understanding regarding the importance of taking enough time and having sufficient resources for effective scale-up to competing public resource allocation priorities at federal and state levels. Furthermore, priorities typically favor treatment over preventive interventions (Catalano et al., 2012). Despite the potential for widespread adoption of effective prevention interventions to reduce costly treatments, only an estimated two to three percent of governmental healthcare spending is directed toward them (Spoth et al, 2013). Knowing this, it is understandable why so many organizations and programs struggle to find sustainable and predictable funding, especially from government sources. Funders tend to want to invest in new and innovative approaches, rather than improving upon those already developed and working (Spoth et.al, 2013). Furthermore, many organizations find themselves competing for local funding sources with other organizations that could be beneficial partners (Stid et al., 2013). However, while government and private foundation funding have important roles to play in the initial stages of creating these programs, even the largest foundations lack the resources for ongoing investments (Hussein & Kerrissey, 2013).

Given the importance of sustainable financial resources, it is essential that funders recognize their role in, and the value of, investing in the full process of developing and scaling-up effective programs. “Funders should balance support and accountability functions, build strong relationships with grantees, give enough time and money to get it right, and help [programs] stay laser-focused on fidelity” (Stid et al., 2013). When applicable, state government, federal and state Medicaid authorities, and private payers should work together to develop coherent funding streams (George et al., 2008).

Recommendations

Several detailed checklists have been developed to guide the process of scaling-up an EBP (Gottfredson et al., 2015; Management Systems International, 2012; Metz et al., 2015; Meyers et al., 2012; Spoth et al., 2015). Here, we highlight a set of general recommendations for varied players.

No single approach is being taken to scale up evidence-based programs. Yet, as more and more effective programs are replicated and studied, we are learning more about what it takes to successfully scale-up a program and the critical factors that support quality implementation on a larger scale. Through our review of the literature and conversations with staff at more than a dozen evidence-based programs, we identified recommendations for various key players for how they can support effective scale up.

Recommendations for funders:

  • When investing in programs that do not have evidence of effectiveness through rigorous evaluation, make obtaining evidence a priority before funding the replication of a program.
  • When investing in evidence-based programs, provide sufficient funding for the infrastructure that can ensure that implementation is high quality, from staff training to data monitoring.
  • Work with the program to ensure that there is a plan for sustainable funding streams.

Recommendations for communities:

  • Select programs carefully. A program should address the needs of the community and should have clearly defined infrastructure requirements that do not exceed the capacity of the community (or that have a plan for building the capacity of the community as part of implementation).
  • Repositories of programs such as the Child Trends’ What Works Lifecourse Interventions to Nurture Kids Successfully (LINKS) database are a good starting place to identify potential programs. However, most communities should undertake a needs and/or fit assessment before selecting a program.

Recommendations for program providers (e.g., national organizations, purveyors, program developers, non-profit organizations, and service providers):

  • Identify the core components of a program and document them thoroughly.
  • Conduct a needs assessment before going into a new community or expanding a program to a new population.
  • Build relationships and capacity within a community well before implementation on the ground begins.
  • Require that all staff be trained to deliver a program prior to implementation and provide ongoing technical assistance throughout the initial implementation period, which may be several years.
  • Conduct systematic monitoring of fidelity and outcomes data.
  • Identify sustainable funding sources for all the aspects of program implementation listed above.

This report was produced with funding from the Edna McConnell Clark Foundation.

References

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