It won't happen unless we make it happen

The challenges of program implementation were the focus of much attention and concern at the 2010 Blueprints for Violence Prevention Conference in San Antonio.

An opening plenary celebrated the huge success of Blueprints in bringing to national and international recognition the value of interventions that have proven impact on children’s health and development. But, even for the most successful, progress is limited.

MultiSystemic Therapy (MST) is now delivered by 345 Teams in 31 US states. But as Karen Blase from the National Implementation Research Network told delegates, that represents a market penetration rate of a meager one per cent.

Nurse Family Partnership also operates in 31 states and reaches further than MST but only to 15 per cent of eligible new parents.

There have been many comparisons in San Antonio between the failure of Blueprints to go to scale and the success of products prepared by big pharmaceutical companies. The latter take over a decade to prepare an evidence based product. But once it has been fully tested, the drug goes rapidly to scale.

Similar development time is needed for a Blueprints program, but it is taking a least another decade to achieve even modest levels of market penetration.

Part of the problem is the case-by-case approach. Typically the originators of evidence based programs adopt a strategy described by Trisha Greenhalgh at University College London as "letting it happen". The program is available to anyone that can find out about it and wants to make it happen. The more successful programs do a little more by ‘helping it happen’.

Big pharmaceutical companies do not think in these terms. They are in the business of "making it happen".

What prevention scientists can do effectively is research what leads to effective implementation of evidence based programs. The Oregon Social Research Center are leading the way with their CAL-OH implementation trial. CAL represents California. OH indicates Ohio. The trial seeks to find out what leads to effective implementation of the proven model Multidimensional Treatment Foster Care.

All counties in California with sufficient numbers of troubled young people have been randomly allocated to two groups. The first implements MTFC in the usual way. The second is supported by a "community development team."

The trial is trying to answer two questions: which of the two groups of counties implements MTFC quicker, and which implements better.

In this second test, ‘better’ means how far they complete eight stages of implementation beginning with initial engagement and ending with sustainable application of the model to the satisfaction of the Oregon team.

The full results will not be available for some time. But the initial findings are interesting if not surprising. Big counties with lots of young people eligible for MTFC implement quickest and best. Rural counties with few eligible cases do the worst.

What is happening next is perhaps indicative of the way prevention scientists approach questions of implementation. MTFC implementers have added a component to help rural counties.

And so it is with the development of most evidence based programs. Whereas most developers of most successful products are working to make them smaller, faster and more efficient, every year of an evidence based programs existence tends to make them bigger, slower and less agile.

See also: The less "unwitting" way to get results