OVERVIEW AND EVIDENCE BASE
What do we mean by this process?
Implementing Effective Interventions is a process of assuring that key aspects of promising approaches are put into practice as intended and to meet local needs. When groups engage in this process, they prioritize and implement intervention strategies based on what has been learned through research and experience in community contexts. "Best practices" are proven programs or policies shown to be effective with a particular issue and specific population. Despite evidence indicating their effects, "best practices" are not always effective in new or different situations. For example, increasing access to health services by lengthening clinic hours may not improve outcomes if language issues are the actual barriers. Implementing Effective Interventions often requires Assuring Technical Assistance and adapting interventions to different or changing conditions, especially when programs or policies are applied in different populations, places, and situations. The process of Implementing Effective Interventions can help community initiatives combine their understanding of what has worked elsewhere with local conditions and opportunities to improve outcomes for a "real-world" impact.
Implementing Effective Interventions is a key process to help communities target and change community conditions for behavioral and population-level improvements.
How it works
Extensive resources have been devoted to prevention research for over 20 years, and programs and strategies that work have been identified. A number of online resources have been developed to increase access to these evidence-based programs and practices and to disseminate effective "program packages" such as curricula manuals and technical assistance guidance (See Best Practices: Links to Intervention Reviews and Recommendations). Review and use of "best practices" can increase selection and application of effective strategies by decision-makers, practitioners, and program funders who must choose among potential innovations to address complex and challenging problems (Brownson, Baker, Leet, & Gillespie, 2003). Yet, there is no perfect program package that can be directly applied across all communities and achieve desired effects. The strict application of evidence-based interventions that emerge from science to community practice does not guarantee success. A "one-size-fits-all" approach will not work (Glasgow, Klesges, Dzewaltowski, Bull, & Estabrooks, 2003; Sorensen, Emmons, Hunt, & Johnston, 1998). Different settings and populations present a range of cultural, economic, and other environmental circumstances that affect behavior and outcome. As such, the process of implementing interventions that work includes respect for both scientific evidence regarding effective programs and experiential knowledge of what would likely work in a particular context. The process of Implementing Effective Interventions aims to fit effective strategies with local context.
The debate continues regarding the appropriate balance between "implementation of evidence-based programs with fidelity" and "adaptation to different community contexts" (e.g., Aos, Lieb, Mayfield, Miller, & Pennucci, 2004). Accordingly, an integrated process of Implementing Effective Interventions may help community initiatives to:
- Use a combination of interventions of varying intensity (e.g., providing information versus modifying policy) that target multiple levels of influence on behaviors (e.g., individual, family, organizational and social environments) (Kreuter, Lezin, & Young, 2000; Sorensen, Emmons, Hunt, & Johnston, 1998). For example, health education classes on how to cook nutritious meals may not be enough to change dietary behaviors in poor neighborhoods when fresh produce costs as much as 22% more than in higher-income areas.
- Respond to community needs with "ecologically-valid" interventions, and generate community support by utilizing local resources for change (Merzel & D'Affliti, 2003).
- Avoid common pitfalls and challenges such as (a) Experiencing short-lived gains that fail to survive beyond a project's limited funding period, (b) Experiencing limited or modest effects due in part to insufficient tailoring to reflect community conditions or to reach different segments of the community, or (c) wasting limited resources by implementing popular interventions that have repeatedly failed to demonstrate effectiveness (Merzel & D'Affliti, 2003; Mitchell, Florin, & Stevenson, 2002).
- Tailor interventions to target at-risk populations and improve intervention effectiveness (Sorensen, Emmons, Hunt, & Johnston, 1998).
- Use limited resources in an efficient manner that also complements existing programs (Foster-Fishman, Berkowitz, Lounsbury, Jacobson, & Allen, 2001).
Empirical and Experiential Evidence
Matching intervention strategies to fit needs, objectives, and context is critical for the success of community change and improvement efforts. Few community mobilization efforts have developed and implemented the kind of "upstream" environmental changes (e.g., social and policy influences) that can provide the necessary strength and penetration to effect population-level improvements (Merzel & D'Affliti, 2003). For example, many substance use prevention partnerships in the 1990s gravitated toward "Red Ribbon" and other public information and awareness campaigns (despite no evidence that these information-provision strategies reduced alcohol or drug use); and these activities often occurred at the expense of more intensive social policy or regulation efforts to reduce access to alcohol and other drugs (Florin, Mitchell, & Stephenson, 1993; Kreuter, Lezin, & Young, 2000). Yet, through assessment and strategic planning activities, other groups such as a Minnesota farm injury prevention coalition determined that farmers in their area first needed to understand and believe that farm injuries were not random acts of fate; accordingly, their public information interventions occurred simultaneously or sequentially with other strategies to change worker behaviors (Lexau et al., 1993). Similarly, Project Northland, a community and school-based alcohol prevention study, targeted community and policy levels, and achieved significant reductions in alcohol and tobacco use among youth populations (Perry et al., 1996). In addition, Project ASSIST and Tobacco Policy Options for Prevention reported reductions in smoking prevalence rates, suggesting that effectively implementing policy changes provided the basis for a health-promoting environment (Sorensen, Emmons, Hunt, & Johnston, 1998).
Adapting interventions to fit population and context also appears to be a critical factor related to effectiveness. Many interventions aim to target multiple levels for change such as individual, family, organizational, state policy. This ecological approach is based on the idea that communities are made up of individuals who interact in a variety of social networks and within various contexts (Brownson, Baker, Leet, & Gillespie, 2003; Roussos & Fawcett, 2000). In Project COMMIT, community planning boards and coalitions were involved in public education, media programs, policy changes, and other programmatic strategies for smoking prevention (Thompson, Corbett, Bracht, & Pechacek, 1993; Thompson, Wallack, Lichtenstein, & Pechacek, 1991). Yet, standardized intervention and research protocols mandated program activities. The program had no impact on quit rates or the smoking behaviors of heavy smokers, the primary target population (COMMIT Research Group, 1995a, 1995b). Herein, protocols may have constrained communities from adapting the program to meet local needs (Merzel & D'Affliti, 2003; Sorensen, Emmons, Hunt, & Johnston, 1998). Similarly, in the absence of effects, community members criticized the South Carolina Heart to Heart Project for not tailoring physical activity programs to reach African Americans who represented 35% of the target population (Goodman, Wheeler, & Lee, 1995).
In a recent effort to transfer research knowledge to practice, investigators attempted to extend the effectiveness of a "popular opinion leader" (POL) approach for HIV prevention from rural white gay men to other populations and settings. Original research indicated the efficacy of this social network intervention, delivered and modeled in outreach fashion by members of one's own social peer group, to reduce HIV infection (Kelly et al., 1991, 1992, 1997). After one-year in the Mpowerment Project, the proportion of intervention men engaging in unprotected anal intercourse decreased by 27% from baseline (p<.05) compared to a 3% increase in a matched comparison (Kegles, Hays, & Coates, 1996). Sikkema et al. (2000) extended the efficacy of the POL approach to target sexual risk behaviors of African American women. By contrast, POL studies targeting male prostitutes and patrons of New York City huster bars (Miller, Klotz, & Eckholdt, 1998) and gay men in London and Scotland (Elford, Hart, Sherr, Williamson, & Bolding, 2002; Flowers, Hart, Williamson, Frankis, & Der, 2002) reported no changes in sexual risk taking behaviors. Originally designed to target cohesive, explicit, social networks, the POL approach (a) was less able to affect behaviors among non-gay-identified men who have sex with men, and (b) did not generalize to peer interactions among non-United States gay cultures. Accordingly, the successful implementation of interventions such as POL appears to require (1) Defining and understanding targeted groups and social networks, and (2) Matching effective intervention strategies to the local context.
Overall, community change and improvement efforts, often unstaffed and dependent on volunteer labor, may be poorly equipped to accomplish the time-consuming tasks of selecting, tailoring, and sustaining effective implementation of interventions for long-term outcomes (Kreuter, Lezin, & Young, 2000). Other key processes that can build capacities to address these challenges include Developing a Framework or Model of Change, Developing and Using Action Plans, Assuring Technical Assistance, and Making Outcomes Matter.
Implications for Research and Practice
At present, much of the information available on Implementing Effective Interventions does not explicitly manipulate or test this process and its effects on community change and improvement. Although this process has been identified as a key ingredient for advancing change, there is a need for more systematic evaluations of its implementation and effects. Such research would provide a better understanding of the factors that enable communities to come together and address shared problems and goals.
Some key research questions include: (a) What conditions influence selection and faithful implementation of effective interventions? (b) What differential effects result from practitioner versus researcher implemented strategies? (c) What "promising," yet un- or under-evaluated interventions are associated with improvements in behavioral and population-level outcomes? (d) What are the cost-benefits of policy strategies (e.g., legislative mandates, pricing policies, restrictions on advertising) on population-level outcomes? (e) What does current knowledge suggest about how interventions should balance adoption and effective use of evidence-based and community-recommended strategies for change? And (f) How can use of evidence-based interventions be made easier and more likely by community practitioners?
Overall Recommendation for Practice
Based on research and experience, we recommend Implementing Effective Interventions as a key process to advance community change and improvement