A casual browse of Prevention Action will highlight the multitude of evidence-based programs available to a commissioner of services for children. Yet the implementation of these programs remains patchy and take-up of evidence-based programs is far from universal. Programs are delivered in isolated schools or communities and very rarely accessible for all children.

The challenges of the wider implementation of evidence-based programs are plentiful. Nevertheless, this remains an important priority for the prevention science community. US-based Lawrence Aber and colleagues, writing in a recent edition of the journal Development and Psychopathology, argue that “from a public health and human rights perspective, it is irresponsible to leave 75 per cent of our country’s children who suffer from mental, emotional and behavioral disorders untreated”.

Translational (or implementation) science deals with questions of how evidence-based programs can be successfully transported from the lab into systems and into public policies. Whilst not providing solutions, Aber identifies five major challenges currently facing those at the frontier of this burgeoning new science that must be addressed in order to extend the current reach of evidence-based prevention and intervention.

The first challenge that they identify is understanding and addressing front-line practitioner beliefs, attitudes and preferences that run counter to evidence-based practice. According to Aber, frontline practitioners of prevention programs are motivated by humanistic concerns such as the desire to help children and professional concerns such as the inclination towards autonomy. They also have their own preferences for different helping behaviors and, regardless of the absence of any hard evidence believe, that their efforts have a positive impact on children.

The writers argue that “although these motives are noble, they can sometimes run counter to a culture of proof and the requirements of fidelity of implementation to the specified model”. Thus, in order for translational research to advance, we need to help practitioners embrace the notion of evidence and all of the rigour that an evidence-based approach entails.

Aber and colleagues argue that many well-known evidence-based programs have strong similarities to food brands. He says many programs “are smartly packaged, have a unique identity, often are associated with a special taste, develop a customer following, and perhaps have a method to market the brand elsewhere”.

An important point about brands, says Aber, is that is not always clear which, of all the ingredients, are essential. What are the vitamins, minerals and proteins of the intervention? What are the critical social, emotional, emotional, cognitive and behavioral processes that help reduce children’s difficulties and improve their outcomes?

Thus the second challenge, Aber argues, is that we need better ways of identifying and reliably measuring the causal agents active in prevention programs and that this is crucial for replication and scale-up of evidence-based approaches. [See: Move aside programs, step up practice for a review of the pros and cons of the “active ingredients” approach to implementation].

The third challenge is to test the influence (on the effectiveness of interventions) of the organisation, community and policy contexts in actually existing, real situations. The traditional sequence of prevention research starts with an efficacy trial (testing an intervention in controlled conditions), to effectiveness trials (testing the same program in more typical, less favorable conditions), to implementation of the program to larger groups of service user, and sustainability (embedding evidence-based approaches in systems and policies).

The ability to adapt and implement a program at each stage in this sequence requires an understanding of how those contexts differentially impact on the relationship between causal agents and outcomes. How does context influence impact when programs are more widely implemented?

Expanding partnerships beyond programs to include systems managers and policy-makers is seen as the fourth challenge because testing interventions under real-world conditions requires such engagement and partnership. What is more, the wide-scale implementation and testing of programs at a sustainable level requires engagement with policy-makers and the public.

Research teams must strive to better understand and tap into what these different stake-holders consider to be evidence-based practice, what they consider credible evidence and what they consider to be relevant for them. Aber maintains that the prevention science community must “develop approaches to tap existing core values of communities and societies if it ever hopes to garner the support necessary to move from programs to systems to policies”.

The final challenge is that in order to meet the demands of the first four challenges, prevention science must adopt a broader, bolder approach. Those at the frontiers of translational research need to conceptualize and frame their work differently, say the researchers.

One of the major themes of this approach is an acceptance of a dynamic and iterative relationship between research and practice, whereby each influences the other. Research informs practice, and practice informs research. It is in the big bold approach that a shift will be made from patchy implementation of branded programs towards broadly enacted, far-reaching, evidence-based policies.

Reference:
J.Lawrence Aber, L., Joshua L. Brown, Stephanie M. Jones, Juliette Berg and Catalina Torrente, “School-based strategies to prevent violence, trauma, and psychopathology: The challenges of going to scale,” Development and Psychopathology (2011), 23, 411-421.