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C 2004) Prevention Science, Vol. 5, No. 1, March 2004 (°
Advancing Prevention Science and Practice: Challenges, Critical Issues, and Future Directions Gilbert J. Botvin1
Progress in identifying effective programs and policies for preventing tobacco, alcohol, and illicit drug use has stimulated a growing sense of optimism about the potential of prevention science and practice. This paper summarizes some of the key challenges and critical issues that still need to be addressed for the advances of the past two decades of prevention research to have an impact on the nature of prevention practice and eventually translate into reductions in mortality and morbidity. In addition to identifying effective strategies for disseminating the use of evidence-based prevention programs and policies, issues related to implementation fidelity and adaptation need to be better understood as well as factors associated with institutionalization of effective prevention programs. Further advances in prevention science and practice will require a new emphasis on blended research models that involve conducting prevention research in practice settings with the active collaboration of researchers and practitioners. KEY WORDS: prevention; implementaion fidelity; adaptation; dissemination; future directions.
INTRODUCTION
ultimately ameliorate the health and social problems being targeted. No doubt a major change in the way prevention is conducted throughout the country has come from initiatives by several federal government agencies to identify prevention programs for which there is credible empirical evidence of effectiveness. Federal agencies with missions related to prevention such as the National Institute on Drug Abuse (NIDA), the Center for Substance Abuse Prevention (CSAP), the Centers for Disease Control and Prevention (CDC), the U.S. Department of Education’s Safe and Drug Free Schools program (SDFS), and the U.S. Department of Justice’s Office of Juvenile Justice and Delinquency Prevention (OJJDP) have developed initiatives intended to influence prevention practice by promoting evidence-based prevention approaches. All of these agencies have identified effective prevention programs and policies, published lists of model or exemplary programs, and conduct conferences to disseminate information on what works. And three practice-oriented agencies (CSAP, OJJDP, and SDFS) have provided funding to support large-scale adoption and implementation of evidence-based prevention programs.
Significant advances in prevention research have been made over the past two decades. Although clearly not all prevention programs and policies are effective, a growing number of high quality studies show that at least some prevention approaches work with some problems and under some conditions. Particularly noteworthy is progress made in school-based drug abuse prevention, both because of its public health importance and its potential for reaching a large number of individuals at a critical developmental period. As the empirical literature has grown, so too has a sense of optimism about the potential of prevention. Promoting Adoption of Evidence-Based Prevention The accumulation of scientific evidence supporting specific prevention programs and policies has led to increasing efforts to disseminate the most effective approaches to influence prevention practice and 1
Institute for Prevention Research, Weill Medical College of Cornell University, 411E. 69th Street, KB-203, New York, New York 10021; e-mail:
[email protected].
69 C 2004 Society for Prevention Research 1389-4986/04/0300-0069/1 °
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70 These efforts have had a growing impact on prevention practice throughout this country. However, despite these efforts, we are still at the beginning of the diffusion process. Estimates suggest that fewer than 30% of schools in America are implementing evidence-based programs (Ringwalt et al., 2002). Using terminology from Rogers (1995) diffusion of innovation theory, Dusenbury and Hansen (2004) note that the prevention field is in the early majority phase of adopting evidence-based prevention programs. To foster continued adoption, Dusenbury and Hansen argue, prevention programs will need to be further refined to increase their simplicity, flexibility, and ease of use. At the same time, research needs to be conducted to identify malleable factors influencing adoption, implementation, and institutionalization. Importance of Implementation Fidelity Beyond challenges associated with disseminating information about evidence-based prevention programs and promoting their adoption, it has become increasingly clear that there are also important challenges related to implementation. One such challenge concerns implementation fidelity. If prevention programs are not implemented with adequate fidelity, it is unlikely that they will be effective. In fact, research shows that high fidelity leads to superior outcomes, whereas poor fidelity leads to decreased effectiveness (Elliott & Mihalic, 2004). Difficulties in achieving high fidelity are widely reported in field settings and concerns about fidelity are heightened by empirical findings (Gottfredson & Gottfredson, 2002). This raises the specter that as evidence-based prevention programs are taken to scale, they may not result in the outcomes expected because of poor fidelity in natural settings. Barriers to Fidelity A fundamental question, of course, is why are teachers and other program providers implementing prevention programs with poor fidelity? There appear to be a variety of reasons. There are a number of potential barriers to fidelity in schools and other realworld settings. These include a lack of training and support, limited resources, classroom overcrowding, classroom management and disciplinary problems, low teacher morale and burnout, multiple competing demands, and insufficient time due to an increased emphasis on basic academic areas and preparation for standardized testing. Research is therefore necessary
Botvin to increase our understanding of the obstacles to high implementation fidelity and how to surmount them. Fidelity Versus Adaptation In addition to these barriers, prevention programs may not be implemented with fidelity because of the perceived need for local adaptation. Although the pursuit of implementation fidelity offers the benefit of improved effectiveness, adaptation may offer potential benefits as well. Those who argue for adaptation, maintain that some obvious benefits of adaptation include the potential for tailoring programs to local needs, increasing acceptability and “buy in,” and increasing cultural relevance. On the other hand, adapting evidence-based prevention programs by deleting material carries with it the risk of inadvertently deleting one or more essential elements and undermining effectiveness. Whereas adapting proven programs by adding untested material or modifying aspects of any evidence-based prevention program also has the potential of undermining effectiveness by including material that may, inadvertently, actually increase risk. At this point, little is known about the benefits/risks of adapting evidence-based prevention programs to different populations. Elliott and Mihalic (2004) forcefully argue that every effort should be made to promote a high degree of implementation fidelity and preserve program integrity. Using evidence from the Blueprints Violence and Drug Abuse Prevention Initiative, they make the case that evidence-based prevention programs can be implemented on a wide scale with both high fidelity and sustainability. They also argue that, contrary to the conventional wisdom, the implicit assumptions underlying the various arguments for adaptation are not supported by existing data. Elliott and Mihalic caution that if prevention programs are not implemented with fidelity they are unlikely to be effective. Cultural Tailoring One common reason often given by teachers and administrators for adapting prevention programs is to culturally tailor them to ethnic minority youth. Castro et al. (2004) present a compelling case for adaptations designed to render prevention programs more appropriate to ethnic/racial minority populations. In some instances, they argue, there may actually be a cultural mismatch between a particular program and the population of students receiving the program. Such a mismatch might undermine the effectiveness
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Advancing Prevention Science and Practice: Challenges, Critical Issues, and Future Directions of the program, hamper implementation, and emerge as a barrier to institutionalization. In other situations, improving the fit of prevention programs offers the potential of increasing buy-in, perceived relevance, and the likelihood that programs will be maintained beyond a short period of use following its initial adoption. Observations that some degree of adaptation may be viewed by program providers as necessary to improve the cultural fit between prevention programs and students are supported by research showing that teachers working with minority populations were more likely to adapt prevention curricula in an effort to make them more culturally appropriate for their students (Ringwalt et al., 2004). At the same time, Castro and his colleagues (2004) acknowledge the natural tension between fidelity and adaptation. They argue that both are essential elements of prevention program design and are best addressed by a planned, organized, and systematic approach. One approach to dealing with the issue of cultural tailoring without jeopardizing program effectiveness by undermining program integrity offered by Castro et al. is to develop prevention programs that “build in” adaptation to enhance program fit while also maximizing fidelity and effectiveness. Currently, there is considerable controversy concerning the extent to which evidence-based programs should be adapted, but little empirical evidence to guide practitioners. More research is clearly needed to determine how to implement programs with fidelity on a largescale in a way that will impact on local, state, or national rates of violence and drug use. Given the reality that at least some teachers adapt prevention programs, Ringwalt and his colleagues suggest that developers should learn more about how teachers are modifying their programs and incorporate these modifications in their curricula wherever possible. Research is also necessary to identify how to insure that prevention programs meet the needs of the students receiving them. Castro and his colleagues suggest that future research should expand current prevention models to include cultural variables and adaptation issues. Institutional Support Structures As Greenberg (2004) points out, we are likely to see broad dissemination of evidence-based programs over the next decade. While broad program diffusion takes place, it is crucial that prevention re-
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search continues along with increased program integration at the school and community level. On a practice level, it is important to identify appropriate structures and systems for dissemination, training, technical assistance and ongoing support, program integration across developmental stages and the prevention/treatment continuum of care, and the institutionalization and sustainability of prevention programs. Spoth and his colleagues (2004) have suggested the utility of a partnership model that offers the potential for building capacity for diffusion of evidencebased prevention programs through the Cooperative Extension System. This involves two different delivery systems: the Cooperative Extension system of land grant universities and the public school system. The Cooperative Extension and the public school system have independent, multilevel program delivery networks reaching every community or district in the country. Such a model offers considerable potential as a delivery system with extensive penetration to promote the adoption, implementation, and institutionalization of evidence-based prevention.
New Prevention Approaches Several of the papers in this issue indicate the need to further refine existing prevention models as well as to explore development of potentially more powerful new approaches. Although efficacy research will remain important for testing these new approaches, a shift in emphasis from efficacy research to effectiveness research in real-world settings will facilitate the integration of research and practice and potentiate the utilization of prevention programs that are tested and proven effective.
Monitoring Systems Greenberg (2004) advocates for the development of standards and accountability systems related to school success. Biglan (2004), on the other hand, argues for the development of monitoring systems to evaluate ongoing prevention practice as well as overall youth functioning. Together, they make a strong case for developing large-scale monitoring systems for empirically determining whether evidence-based prevention programs and policies are having the intended impact on health and well-being.
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Future Research Directions Despite the impressive progress made to the field of prevention in recent years, considerably more work is needed to advance both the science and practice of prevention. Research is needed to refine current prevention approaches, test new approaches, identify mediating mechanisms, understand the factors associated with poor fidelity and how to surmount them, determine whether adaptation is necessary to make prevention programs suitable to different populations as well as how to adapt evidence-based prevention programs without undermining their effectiveness, determine the effectiveness of current prevention approaches with minority populations, test the optimal combination of prevention modalities together to create effective comprehensive prevention strategies, and extend current prevention findings to multiple problem behaviors. Pentz (2004) and Biglan (2004) suggest research designs for the next generation of prevention trials, addressing gaps in our understanding of the stages of diffusion, methods for increasing the use of effective programs, and research elucidating a range of putative mediators and contextual factors. Pentz emphasizes the use of classical experimental designs and randomized control trials. Biglan advocates for a greater understanding of the validity and potential contribution of single case designs. Future Practice Directions Other important next steps are to increase the adoption and use of proven prevention approaches, develop and test new dissemination structures and systems, develop and test new blended research models that test evidence-based prevention in natural practice settings. To successfully achieve these important goals, it is necessary to develop stronger and more collaborative relationships with teachers and other providers of prevention programs in school settings. CONCLUSION As Biglan (2004) states, the most daunting challenge for prevention science will be to effectively translate the results of the last 20 years of prevention research into reductions in the incidence or prevalence of problem behaviors. To meet that challenge, the Society for Prevention Research (SPR) has de-
veloped a comprehensive strategic plan to guide future research initiatives and promote the use of prevention programs that have been rigorously tested and proven effective. In brief, SPR’s strategic plan is designed to (1) promote federal and state-level initiatives on integration of research and practice, (2) develop standards for the level of rigor required for confident conclusions about the efficacy of prevention practices, and (3) develop and promote use of data systems to measure trends in positive youth development and factors that influence positive youth development at state and local levels. Considerable progress has been made in prevention science, but much work remains to be done. For further advances in both prevention science and practice to occur, it is now abundantly clear that efforts to translate the progress in prevention science into reductions in drug use and other problem behaviors will be necessary to embrace a new blended model of prevention research that involves conducting prevention research in practice settings with the active collaboration of researchers and practitioners. REFERENCES Biglan, A. (2004). Contextualism and the development of effective prevention practices. Prevention Science, 5, 15–21. Castro, F. G., Barrera, M., Jr., & Martinez, C. R. (2004). The cultural adaptation of prevention interventions: Resolving tensions between fidelity and fit. Prevention Science, 5, 41–45. Dusenbury, L., & Hansen, W. B. (2004). Pursuing the course from research to practice. Prevention Science, 5, 55–59. Elliott, D. S., & Mihalic, S. (2004). Issues in disseminating and replicating effective prevention programs. Prevention Science, 5, 47–53. Gottfredson, D. C., & Gottfredson, G. D. (2002). Quality of schoolbased prevention programs: Results from a national survey. Journal of Research on Crime and Delinquency, 39, 3–35. Greenberg, M. T. (2004). Current and future challenges in schoolbased prevention: The researcher perspective. Prevention Science, 5, 5–13. Pentz, M. A. (2004). Form follows function: Designs for prevention effectiveness and diffussion research. Prevention Science, 5, 23–29. Ringwalt, C. L., Ennett, S., Vincus, A., Thorne, J., Rohrbach, L. A., & Simmons-Rudolph, A. (2002). The prevalence of effective substance use prevention curricula in U.S. middle schools. Prevention Science, 3, 257–265. Ringwalt, C. L., Vincus, A., Ennett, S., Johnson, R., & Rohrbach, R. L. (2004). Reasons for teachers’ adaptation of substance use prevention curricula in schools with Non-White student population. Prevention Science, 5, 61–67. Rogers, E. M. (1995). Diffusion of Innovations, The Free Press, New York. Spoth, R., Greenberg, M., Bierman, K., & Redmond, C. (2004). PROSPER community–university partnership model for public education systems: Capacity-building for evidencebased, competence-building prevention. Prevention Science, 5, 31–39.
