Barriers and Incentives to Effective Prevention Program Adoption and Implementation

Literature Review

- Author's Note
- Decision-Making, Policy Setting, and Conceptual Issues
- Program Adoption, Implementation, and Maintenance
- Achieving Effectiveness

Author's Note

Literature Search Strategy

The goal of the literature search was to find research studies and theoretical and methodological reports that represented the theme of the annotated bibliography: barriers and incentives to effective prevention program adoption and implementation. The theme was immediately relevant to the topic of diffusion of innovations research, about which there has been some information published, primarily in the general literature from a body of work initiated by Everett Rogers of the University of New Mexico. A Medline search was begun looking for terms such as diffusion, innovation, barrier, incentives, adoption, implementation and words common to drug abuse prevention such as prevention, drug use, and policy. Few citations were found. Dr. Rogers had one article that was not published in a source to which the library had access. Most of the literature on incentives dealt with economic issues; the term barrier resulted in the contraceptive literature; the term adoption was related to many different fields; diffusion did result in several interesting articles. On the other hand, prevention and drug use as terms resulted in many publications, but only a few were related to the adoption and implementation of prevention programs. Nonetheless, a sufficient number of articles were identified that key journals in which this literature had been published could be located. Once key articles were identified, a general search through the tables of contents of these journals was made. Approximately half of the articles identified by title were extracted. The remainder were either off the topic of interest or were in sources that could not be located.

Summary of Findings

The literature that was extracted and annotated has three major areas of focus. The first area has to do with decision-making, policy setting, and conceptual issues related to program adoption and implementation. Much of this literature had a political bent; the literature discussed the role and nature of politics in decision-making, the structure of prevention policies and programs, and organizational incentives and barriers. The second area dealt with topics more directly related to the diffusion of innovations literature. These articles dealt with evaluating the adoption, implementation, and maintenance of specific prevention programs. This literature was relatively sound in its scientific methods and was clearly rooted in diffusion of innovation theory. The final area of focus addressed achieving effectiveness among programs that had been disseminated (in other words, programs that were beyond the efficacy trial stage). This literature points to training and support functions that may be necessary not only for program adoption, but for the implementation of programs in ways that achieve results. It is quite clear that all three areas are required for drug use prevention programming to achieve its ultimate goal of society-wide effectiveness.

Missing Elements

There remain many topics about which literature could not be found. For example, although there are some studies that feature community-based programs, the school-based literature predominates. In part this reflects an ease of identification that is associated with schools; every community has schools, not every community has established prevention organizations. This also reflects the nature of funded research; schools as units are easier to randomize and intervene with than are community organizations. There was also little research about adoption and maintenance issues of the most common or visible programs. For example, DARE has an extensive emerging literature about effectiveness, but there is no scientific literature about program adoption and implementation. There is no literature about program maintenance in the face of poor evaluation findings or about communities that have dropped DARE in response to scientific findings about its lack of effectiveness. There is a similar lack of information about other commercially available projects. One suspects the operation of political and marketing machines, but these topics are not discussed often in the scientific literature.

Sections

Decision-Making, Policy Setting, and Conceptual Issues

Butterfoss, F. D., Goodman, R. M., & Wandersman, A. (1996). Community coalitions for prevention and health promotion: Factors predicting satisfaction, participation, and planning. Health Education Quarterly, 23 (1), 65-79.

This article examines the strengths and weaknesses of community coalitions as prevention programming facilitators. Communities have placed a great deal of hope on the ability of coalitions to provide a means of directing community action toward prevention. This study identifies conditions that promote effective coalition functioning. Leadership was the primary predictor of success, satisfaction, and participation. The practical lessons learned from this study focus attention on the selection of effective community leaders (skilled and prestigious individuals who can unite coalition members). Coalitions require cohesion, a task-orientation, and a tolerance of innovation in order for positive outcomes to emerge. Contention, turf defense, and divided or ineffective leadership clearly serves as a barrier to the adoption of prevention programs, policies, and plans.

The fact that no measures of group structure or performance were related to producing technically meritorious plans, identifying appropriate objectives or scope, or using resources appropriately is a reason for concern. (Plans were not evaluated from a framework of research-based support for potential, only for completeness of detail for how plans might be implemented.) Coalitions can be productive in that they can generate enthusiasm, support, and agreement about goals, and still not be effective as either decision makers, planners, or implementers.

Chambliss, W. J. (1994). Why the U.S. Government is not contributing to the resolution of the Nation's drug problem. International Journal of Health Services, 24 (4), 675-690.

This article is directed at Federal and State policy makers. The tone of the article is polemic and hyper-critical of the focus of current drug policy that promotes enforcement and minimizes prevention, treatment, and harm reduction. The article obliquely reviews the Dutch, Swiss, and Spanish approaches to drug control that have avoided the emphasis on law enforcement strategies. Despite its style, there is useful information about how, during the course of the "war on drugs," incarceration has doubled, but the availability of illicit drugs has essentially not changed. The author points to the fact that government policy makers have repeatedly chosen to adhere to ideology rather than science and research as the basis for decision-making.

Dembo, R. (1995). A personal reflection on information control and agency failure: The case of the New York State Drug Agency, 1973-1976. International Journal of the Addictions, 30 (5), 587-600.

This article documents specific instances in which negative evaluation findings were systematically suppressed in a State agency. Because findings were suppressed, solutions to problems were not addressed, and the agency was eventually dismantled. The author concludes that agencies that ignore scientific information about program effectiveness and performance are all too common and ultimately fail in their primary mission. The implications are that evaluation studies that may help make valid decisions may often be suppressed, causing failure in program selection and implementation which may ultimately lead to seriously flawed responses to drug use problems.

Glicksman, L., Allison, K., Adlaf E., & Newton-Taylor B. (1995). Toward comprehensive school drug policy in Ontario. Journal of Drug Education, 25 (2), 129-138.

The article reports about the state of practice in Ontario, Canada regarding school district adoption of drug policies. A survey of 125 school districts in Ontario was conducted in the fall of 1991. The Ontario Ministry of Education required each school district to develop comprehensive drug education policies in 1990 that were to be fully implemented by 1991. The Ministry endorsed the following four concepts as being part of a comprehensive policy: (1) prevention curriculum (grades 7 through 12); (2) early interventions; (3) disciplinary procedures; and (4) community partnerships. This article deals with the presence of policies about the first three topics.

Even prior to the mandate, 46% of school boards had adopted some form of drug policy. Most of these (83%) dealt with discipline, and fewer dealt with prevention curricula (41%) or early intervention (31%). At the time of the survey (after the mandate), 88% indicated they would have some form of prevention policy in operation, 90% indicated they had adopted or developed and were implementing prevention curricula, 62% had early intervention available, and 76% of secondary schools (83% of elementary schools) have disciplinary procedures in place. Among the major resources made available to schools was help from the Addiction Research Foundation. Because the Foundation is funded as an entity (without project-specific mandates as most research institutes in the United States), significant personnel time was dedicated to assisting districts in developing policies (83% of boards made use of materials supplied by the Foundation). The development of a clear but flexible mandate and the availability of resources clearly provided an incentive for schools to develop and implement drug prevention policies.

Goodman, R. M., McLeroy, K. R., Steckler, A. B., & Hoyle, R. H. (1993). Development of level of institutionalization scales for health promotion programs. Health Education Quarterly, 20 (2), 161-178.

Worthy programs that are adopted for trial may not be sustained. (On the other hand, programs with no effectiveness may be sustained beyond their usefulness. However, this is not discussed in this paper.) Institutionalization implies that a program has become embodied within and integral to the organization within which it is housed and is viewed by the authors as a key to the long term effectiveness of any program's success. Once institutionalized, a program ceases to stand out as novel and becomes a part of an organization=s standard operating procedure. When fully institutionalized, elements of the program are replaced without question, including personnel. Funding program costs becomes routine.

This article presents data about the measurement of a scale to measure program institutionalization (LoIn) that was developed and tested with organizations that operate health promotion programs in three southern States (North Carolina, South Carolina, and Virginia) and three western States (Arizona, Montana, and Utah). Eight factors were identified. Four concerned routinization and four concerned niche saturation. For each, a production, maintenance, support, and management factor was identified. Routinization generally reflected the duration of program sustenance whereas niche saturation addressed the number of people, identifiable project components, and depth of organization that existed for current programs. Each of the eight factors was correlated with years of program implementation and perceived permanence of the program. Routinization scores predicted years of program implementation (correlation coefficients for these four factors ranged from .277 to .399). Perceived permanence of the program was most strongly correlated with niche saturation (correlations ranged from .234 to .535). Support niche saturation (r=.535) and maintenance niche saturation (r=.415) were the most important predictors of potential permanence.

These results suggest that beyond adoption, drug prevention programs need to develop definable organizational support patterns. Perceived permanence might be thought of as being more important in that this reflects future intentions of an organization. Institutionalization may require the defined funding of positions. From this perspective, the program itself is secondary to the potential to staff the program. Many prevention programs are developed to be effective but are not developed to be permanent; the skills for developing institutionalization are rarely considered in research-based prevention efforts.

Gorman, D. M. (1993). "War on drugs" continues in United States under new leadership. British Medical Journal, 307 (6900), 369-371.

Butterfoss, F. D., Goodman, R. M., & Wandersman, A. (1996). Community coalitions for prevention and health promotion: Factors predicting satisfaction, participation, and planning. Health Education Quarterly, 23 (1), 65-79.

This article examines the strengths and weaknesses of community coalitions as prevention programming facilitators. Communities have placed a great deal of hope on the ability of coalitions to provide a means of directing community action toward prevention. This study identifies conditions that promote effective coalition functioning. Leadership was the primary predictor of success, satisfaction, and participation. The practical lessons learned from this study focus attention on the selection of effective community leaders (skilled and prestigious individuals who can unite coalition members). Coalitions require cohesion, a task-orientation, and a tolerance of innovation in order for positive outcomes to emerge. Contention, turf defense, and divided or ineffective leadership clearly serves as a barrier to the adoption of prevention programs, policies, and plans.

The fact that no measures of group structure or performance were related to producing technically meritorious plans, identifying appropriate objectives or scope, or using resources appropriately is a reason for concern. (Plans were not evaluated from a framework of research-based support for potential, only for completeness of detail for how plans might be implemented.) Coalitions can be productive in that they can generate enthusiasm, support, and agreement about goals, and still not be effective as either decision makers, planners, or implementers.

Chambliss, W. J. (1994). Why the U.S. Government is not contributing to the resolution of the Nation's drug problem. International Journal of Health Services, 24 (4), 675-690.

This article is directed at Federal and State policy makers. The tone of the article is polemic and hyper-critical of the focus of current drug policy that promotes enforcement and minimizes prevention, treatment, and harm reduction. The article obliquely reviews the Dutch, Swiss, and Spanish approaches to drug control that have avoided the emphasis on law enforcement strategies. Despite its style, there is useful information about how, during the course of the "war on drugs," incarceration has doubled, but the availability of illicit drugs has essentially not changed. The author points to the fact that government policy makers have repeatedly chosen to adhere to ideology rather than science and research as the basis for decision-making.

Dembo, R. (1995). A personal reflection on information control and agency failure: The case of the New York State Drug Agency, 1973-1976. International Journal of the Addictions, 30 (5), 587-600.

This article documents specific instances in which negative evaluation findings were systematically suppressed in a State agency. Because findings were suppressed, solutions to problems were not addressed, and the agency was eventually dismantled. The author concludes that agencies that ignore scientific information about program effectiveness and performance are all too common and ultimately fail in their primary mission. The implications are that evaluation studies that may help make valid decisions may often be suppressed, causing failure in program selection and implementation which may ultimately lead to seriously flawed responses to drug use problems.

Glicksman, L., Allison, K., Adlaf E., & Newton-Taylor B. (1995). Toward comprehensive school drug policy in Ontario. Journal of Drug Education, 25 (2), 129-138.

The article reports about the state of practice in Ontario, Canada regarding school district adoption of drug policies. A survey of 125 school districts in Ontario was conducted in the fall of 1991. The Ontario Ministry of Education required each school district to develop comprehensive drug education policies in 1990 that were to be fully implemented by 1991. The Ministry endorsed the following four concepts as being part of a comprehensive policy: (1) prevention curriculum (grades 7 through 12); (2) early interventions; (3) disciplinary procedures; and (4) community partnerships. This article deals with the presence of policies about the first three topics.

Even prior to the mandate, 46% of school boards had adopted some form of drug policy. Most of these (83%) dealt with discipline, and fewer dealt with prevention curricula (41%) or early intervention (31%). At the time of the survey (after the mandate), 88% indicated they would have some form of prevention policy in operation, 90% indicated they had adopted or developed and were implementing prevention curricula, 62% had early intervention available, and 76% of secondary schools (83% of elementary schools) have disciplinary procedures in place. Among the major resources made available to schools was help from the Addiction Research Foundation. Because the Foundation is funded as an entity (without project-specific mandates as most research institutes in the United States), significant personnel time was dedicated to assisting districts in developing policies (83% of boards made use of materials supplied by the Foundation). The development of a clear but flexible mandate and the availability of resources clearly provided an incentive for schools to develop and implement drug prevention policies.

Goodman, R. M., McLeroy, K. R., Steckler, A. B., & Hoyle, R. H. (1993). Development of level of institutionalization scales for health promotion programs. Health Education Quarterly, 20 (2), 161-178.

Worthy programs that are adopted for trial may not be sustained. (On the other hand, programs with no effectiveness may be sustained beyond their usefulness. However, this is not discussed in this paper.) Institutionalization implies that a program has become embodied within and integral to the organization within which it is housed and is viewed by the authors as a key to the long term effectiveness of any program's success. Once institutionalized, a program ceases to stand out as novel and becomes a part of an organization=s standard operating procedure. When fully institutionalized, elements of the program are replaced without question, including personnel. Funding program costs becomes routine.

This article presents data about the measurement of a scale to measure program institutionalization (LoIn) that was developed and tested with organizations that operate health promotion programs in three southern States (North Carolina, South Carolina, and Virginia) and three western States (Arizona, Montana, and Utah). Eight factors were identified. Four concerned routinization and four concerned niche saturation. For each, a production, maintenance, support, and management factor was identified. Routinization generally reflected the duration of program sustenance whereas niche saturation addressed the number of people, identifiable project components, and depth of organization that existed for current programs. Each of the eight factors was correlated with years of program implementation and perceived permanence of the program. Routinization scores predicted years of program implementation (correlation coefficients for these four factors ranged from .277 to .399). Perceived permanence of the program was most strongly correlated with niche saturation (correlations ranged from .234 to .535). Support niche saturation (r=.535) and maintenance niche saturation (r=.415) were the most important predictors of potential permanence.

These results suggest that beyond adoption, drug prevention programs need to develop definable organizational support patterns. Perceived permanence might be thought of as being more important in that this reflects future intentions of an organization. Institutionalization may require the defined funding of positions. From this perspective, the program itself is secondary to the potential to staff the program. Many prevention programs are developed to be effective but are not developed to be permanent; the skills for developing institutionalization are rarely considered in research-based prevention efforts.

Gorman, D. M. (1993). "War on drugs" continues in United States under new leadership. British Medical Journal, 307 (6900), 369-371.

This article is addressed to policy makers. It is critical of the approach to dealing with the drug problem in the United States. The author claims that the law enforcement approach has been institutionalized and that despite promises in the campaign to the contrary, prevention and treatment efforts are not emphasized in the national allocation of resources. Regarding prevention, the author is critical of social influences approaches and would rather promote programs specifically designed for inner cities.

Howze, E. H., & Redman, L. J. (1992). The uses of theory in health advocacy: Policies and programs. Health Education Quarterly, 19 (3), 368-383.

The key information about barriers to program adoption presented in this article is about how groups with low political visibility and power come to gain that power and the challenges that they face. Included in the description of events are such challenges as denial of access to key players by legislative aides. In addition, it is clear from the description that the language legislators speak is not the same language that health promoters speak. The legislative agenda is often based on economics and maintaining public perceptions about issues that are irrelevant to health concerns (e.g. popularity and within-group power). The group claims success based on three serendipitous events that no amount of planning or lobbying could have controlled (the poor health and eventual replacement of an aide who was blocking progress, the death of a State legislator related to the topic at hand, and an unscheduled champion who spoke to issues independently of the group's efforts).

Keeve, J. P. (1967). Overcoming obstacles to a creative school health programme. International Journal of Health Education, 26-32.

This article is included in the bibliography to point out that obstacles to program adoption and implementation have a long history. In this case, the article notes that organizational conflicts between competing organizations (xenophobia), conflicts between centralized versus localized decision-making, legal barriers and the existence of antiquated legal mandates, and the lack of availability of appropriate diagnostic (evaluative) tools all exist. The tenor of this article demonstrates that, even though we now write about barriers to program adoption and implementation with some sophistication, the issues themselves have not changed.

Lefabvre, R. C., & Flora, J. A. (1988). Social marketing and public health intervention. Health Education Quarterly, 15 (3), 299-315.

This article is written for an audience of health promotion strategists. The point of departure for this article is that programming that is designed for groups is inherently limited. The following points are made: (1) counselling and small group programming has limited potential because of the intense dedication of resources required; (2) there is low penetration of group-based health education, particularly for high-risk populations; and (3) there are limited resources that are available for programming, and these must be used economically. This article reviews eight principles of social marketing and applies them as an alternative to traditional health education. The goal of social marketing is to achieve effects through a mix of methods, none of which alone is expected to accomplish the goals of intervention. Characteristics featured as possible means for implementing health promotion social marketing include: (1) a consumer orientation (as opposed to an expert orientation), (2) an emphasis on voluntary exchanges of goods and services between providers and consumers, (3) research in audience analysis and segmentation strategies (systematically find out what various subgroups of consumers pay attention to), (4) formative research in product and message design, including the systematic use of pilot tests, (5) analysis of distribution channels (how products and services move from producer to consumer with an identification of weaknesses and fail points), (6) use of the "marketing mix" (utilizing and blending product, price, place, and promotional characteristics in intervention planning and implementation), (7) process tracking with both integrative and control functions (know who is doing what, what assistance they need, how they are progressing), and (8) a management process that involves problem analysis, planning, and evaluation functions. The implied message of this article is that these eight functions provide an alternative to the traditional concept of direct health education interventions that are the mainstay of the field today. As a consequence, many of the challenges that face programs are circumvented by using alternative methods. The Pawtucket Heart Health Project and the Stanford Three-Cities Study are reviewed as case studies of social marketing.

Oetting, E. R., Donnermeyer, J. F., Plested, B. A., Edwards, R. W., Kelly, K., & Beauvais, F. (1995). Assessing community readiness for prevention. International Journal of the Addictions, 30, 659-683.

This article is written as a methodological approach to assessing community readiness, but is heavily supported theoretically through adoption of concepts discussed in the Trans-Theoretical Model of Prochaska and DiClemente, Roger's Diffusion of Innovations Theory, and the Social Action Process model. Measures were developed to reflect the model's ten linear (ordered) steps: denial, precontemplation, contemplation, stimulation, initiation, legitimization, initial action, maintenance/expansion, institutionalization, and creative integration. The stages of readiness described are qualitative descriptions. Implied in this method is an ordered set of stages. If communities are not at an advanced stage, it is implied that prior stages must each be completed in sequence. One possible reason for lack of program adoption can be that communities have not progressed through necessary earlier stages. The adoption of prevention programs can be facilitated through analysis which identifies the stage of readiness followed by specific activities within the community designed to move the community to the next stage.

Perhats, C., Oh, K., Levy, S. R., Flay, B. R., & McFall, S. (1996). Role differences in gatekeeper perceptions of school-based drug and sexuality education programs: A cross-sectional survey. Health Education Research, 11 (1), 11-27.

This study describes several issues that are of great importance to understanding barriers to effective prevention related to the roles of various actors and gatekeepers within schools. Notably, of the five roles examined in this study (principals, district prevention program administrators, school board members, teachers, and parents), only those closest to the problem (teachers and parents) provided critical evaluations of programs that had been adopted. This article suggests that administrators (principals, district prevention program administrators, and board members) play the role of gatekeeper, admitting programs to which they are committed. It is likely that in most cases, decisions to approve, adopt, and fund a program are based on some review that is either directed, supervised, or sanctioned by these individuals. However, it is probably that these individuals fail in their decision-making roles in specific ways. They may not have access to evaluation data, may base judgments from ideological rather than effectiveness perspectives, or may be selecting programs based on marketing and public relations efforts. Research-based programs are typically poorly marketed, provide little that fosters institutionalization once adopted, and are poorly supported operationally. In a rational world, ineffective programs should be eliminated eventually through feedback from program users and participants. Unfortunately, the structure of most schools is such that the power differential between administrators and users is likely to be weighted so that users have little input into decision-making. This results in decisions about school prevention programs being seriously flawed. Teachers and parents have little confidence in programs that administrators wholeheartedly support. Once adopted, the perpetuation of such programs serves as a serious barrier to the adoption of effective programs.

Seffrin, J. (1990). The comprehensive school health curriculum: Closing the gap between state-of-the-art and state-of-the-practice. Journal of School Health, 60 (4), 151-156.

This article discusses governmental strategies that might be employed to improve the general availability of health education. This article presents a wish list of improvements that, if adopted, would advance the visibility and effectiveness of health education in schools. The challenge of implementing effective programs is matched by the challenge of establishing management and support roles in Federal, State, and local offices that oversee health education. The author contends that additional governmental offices that can actively promote health education at a national level are needed. Further, additional resources need to be allocated to professional preparation and training. Included in this is specialist preservice training and continuing education for elementary and secondary teachers in health-related areas.

Steckler, A. B., Goodman, R. M., McLeroy, K. R., Davis, S., & Koch, G. (1992). Measuring the diffusion of innovative health promotion programs. American Journal of Health Promotion. 6, 214-224.

This article discusses the theoretical underpinnings of diffusion of innovations and describes six questionnaires that, when administered, provide a quantitative picture of diffusion (awareness, adoption, implementation, and institutionalization). This article is important for its methodologic and theoretic insights. The authors note that the instruments are generic in nature and, even though developed for use specifically in schools, can be adapted for use in other organizations as well.

Witte, K. (1993). Managerial style and health promotion programs. Social Science & Medicine, 36 (3), 227-235.

This study addresses an area slightly outside that of prevention program adoption in that it uses work site programs as the sample. However, the basic issues that are addressed, specifically leadership and management style of companies, may have important implications for decision-making about prevention programming in schools and communities. The authors surveyed middle managers (mostly from human resources and personnel departments) and asked them to provide information about the managerial style of the company. Companies were scaled along authoritarian and democratic management styles. These scores were then related to the presence or absence of health promotion programs (risk appraisal, smoking cessation, high blood pressure control, weight control, nutrition, stress management, back care, accident prevention, and health fairs). Democratic companies were much more likely to have adopted health promotion programs. Reasons for having adopted these programs were related to containing health costs (40%), improving productivity and morale (25%), improving health (25%), and reducing absenteeism (5%). Reasons for not adopting programs had to do with not having enough time (60%), too much expense (30%), no interest by the employer (28%), and no interest by employees (25%). The authors conclude that authoritarian companies engage in 'old' forms of social control and tend to ignore the needs and wishes of their constituency. Democratic companies in contrast exercise 'new' forms of social control. That is, they encourage productivity and loyalty by listening to the constituency's expressed needs and provide opportunities that fulfill these needs. The kind of decision-making processes that institutions go through may have significant implications for their ability to choose and willingness to adopt and implement prevention programs.

This article is addressed to policy makers. It is critical of the approach to dealing with the drug problem in the United States. The author claims that the law enforcement approach has been institutionalized and that despite promises in the campaign to the contrary, prevention and treatment efforts are not emphasized in the national allocation of resources. Regarding prevention, the author is critical of social influences approaches and would rather promote programs specifically designed for inner cities.

Howze, E. H., & Redman, L. J. (1992). The uses of theory in health advocacy: Policies and programs. Health Education Quarterly, 19 (3), 368-383.

The key information about barriers to program adoption presented in this article is about how groups with low political visibility and power come to gain that power and the challenges that they face. Included in the description of events are such challenges as denial of access to key players by legislative aides. In addition, it is clear from the description that the language legislators speak is not the same language that health promoters speak. The legislative agenda is often based on economics and maintaining public perceptions about issues that are irrelevant to health concerns (e.g. popularity and within-group power). The group claims success based on three serendipitous events that no amount of planning or lobbying could have controlled (the poor health and eventual replacement of an aide who was blocking progress, the death of a State legislator related to the topic at hand, and an unscheduled champion who spoke to issues independently of the group's efforts).

Keeve, J. P. (1967). Overcoming obstacles to a creative school health programme. International Journal of Health Education, 26-32.

This article is included in the bibliography to point out that obstacles to program adoption and implementation have a long history. In this case, the article notes that organizational conflicts between competing organizations (xenophobia), conflicts between centralized versus localized decision-making, legal barriers and the existence of antiquated legal mandates, and the lack of availability of appropriate diagnostic (evaluative) tools all exist. The tenor of this article demonstrates that, even though we now write about barriers to program adoption and implementation with some sophistication, the issues themselves have not changed.

Lefabvre, R. C., & Flora, J. A. (1988). Social marketing and public health intervention. Health Education Quarterly, 15 (3), 299-315.

This article is written for an audience of health promotion strategists. The point of departure for this article is that programming that is designed for groups is inherently limited. The following points are made: (1) counselling and small group programming has limited potential because of the intense dedication of resources required; (2) there is low penetration of group-based health education, particularly for high-risk populations; and (3) there are limited resources that are available for programming, and these must be used economically. This article reviews eight principles of social marketing and applies them as an alternative to traditional health education. The goal of social marketing is to achieve effects through a mix of methods, none of which alone is expected to accomplish the goals of intervention. Characteristics featured as possible means for implementing health promotion social marketing include: (1) a consumer orientation (as opposed to an expert orientation), (2) an emphasis on voluntary exchanges of goods and services between providers and consumers, (3) research in audience analysis and segmentation strategies (systematically find out what various subgroups of consumers pay attention to), (4) formative research in product and message design, including the systematic use of pilot tests, (5) analysis of distribution channels (how products and services move from producer to consumer with an identification of weaknesses and fail points), (6) use of the "marketing mix" (utilizing and blending product, price, place, and promotional characteristics in intervention planning and implementation), (7) process tracking with both integrative and control functions (know who is doing what, what assistance they need, how they are progressing), and (8) a management process that involves problem analysis, planning, and evaluation functions. The implied message of this article is that these eight functions provide an alternative to the traditional concept of direct health education interventions that are the mainstay of the field today. As a consequence, many of the challenges that face programs are circumvented by using alternative methods. The Pawtucket Heart Health Project and the Stanford Three-Cities Study are reviewed as case studies of social marketing.

Oetting, E. R., Donnermeyer, J. F., Plested, B. A., Edwards, R. W., Kelly, K., & Beauvais, F. (1995). Assessing community readiness for prevention. International Journal of the Addictions, 30, 659-683.

This article is written as a methodological approach to assessing community readiness, but is heavily supported theoretically through adoption of concepts discussed in the Trans-Theoretical Model of Prochaska and DiClemente, Roger's Diffusion of Innovations Theory, and the Social Action Process model. Measures were developed to reflect the model's ten linear (ordered) steps: denial, precontemplation, contemplation, stimulation, initiation, legitimization, initial action, maintenance/expansion, institutionalization, and creative integration. The stages of readiness described are qualitative descriptions. Implied in this method is an ordered set of stages. If communities are not at an advanced stage, it is implied that prior stages must each be completed in sequence. One possible reason for lack of program adoption can be that communities have not progressed through necessary earlier stages. The adoption of prevention programs can be facilitated through analysis which identifies the stage of readiness followed by specific activities within the community designed to move the community to the next stage.

Perhats, C., Oh, K., Levy, S. R., Flay, B. R., & McFall, S. (1996). Role differences in gatekeeper perceptions of school-based drug and sexuality education programs: A cross-sectional survey. Health Education Research, 11 (1), 11-27.

This study describes several issues that are of great importance to understanding barriers to effective prevention related to the roles of various actors and gatekeepers within schools. Notably, of the five roles examined in this study (principals, district prevention program administrators, school board members, teachers, and parents), only those closest to the problem (teachers and parents) provided critical evaluations of programs that had been adopted. This article suggests that administrators (principals, district prevention program administrators, and board members) play the role of gatekeeper, admitting programs to which they are committed. It is likely that in most cases, decisions to approve, adopt, and fund a program are based on some review that is either directed, supervised, or sanctioned by these individuals. However, it is probably that these individuals fail in their decision-making roles in specific ways. They may not have access to evaluation data, may base judgments from ideological rather than effectiveness perspectives, or may be selecting programs based on marketing and public relations efforts. Research-based programs are typically poorly marketed, provide little that fosters institutionalization once adopted, and are poorly supported operationally. In a rational world, ineffective programs should be eliminated eventually through feedback from program users and participants. Unfortunately, the structure of most schools is such that the power differential between administrators and users is likely to be weighted so that users have little input into decision-making. This results in decisions about school prevention programs being seriously flawed. Teachers and parents have little confidence in programs that administrators wholeheartedly support. Once adopted, the perpetuation of such programs serves as a serious barrier to the adoption of effective programs.

Seffrin, J. (1990). The comprehensive school health curriculum: Closing the gap between state-of-the-art and state-of-the-practice. Journal of School Health, 60 (4), 151-156.

This article discusses governmental strategies that might be employed to improve the general availability of health education. This article presents a wish list of improvements that, if adopted, would advance the visibility and effectiveness of health education in schools. The challenge of implementing effective programs is matched by the challenge of establishing management and support roles in Federal, State, and local offices that oversee health education. The author contends that additional governmental offices that can actively promote health education at a national level are needed. Further, additional resources need to be allocated to professional preparation and training. Included in this is specialist preservice training and continuing education for elementary and secondary teachers in health-related areas.

Steckler, A. B., Goodman, R. M., McLeroy, K. R., Davis, S., & Koch, G. (1992). Measuring the diffusion of innovative health promotion programs. American Journal of Health Promotion. 6, 214-224.

This article discusses the theoretical underpinnings of diffusion of innovations and describes six questionnaires that, when administered, provide a quantitative picture of diffusion (awareness, adoption, implementation, and institutionalization). This article is important for its methodologic and theoretic insights. The authors note that the instruments are generic in nature and, even though developed for use specifically in schools, can be adapted for use in other organizations as well.

Witte, K. (1993). Managerial style and health promotion programs. Social Science & Medicine, 36 (3), 227-235.

This study addresses an area slightly outside that of prevention program adoption in that it uses work site programs as the sample. However, the basic issues that are addressed, specifically leadership and management style of companies, may have important implications for decision-making about prevention programming in schools and communities. The authors surveyed middle managers (mostly from human resources and personnel departments) and asked them to provide information about the managerial style of the company. Companies were scaled along authoritarian and democratic management styles. These scores were then related to the presence or absence of health promotion programs (risk appraisal, smoking cessation, high blood pressure control, weight control, nutrition, stress management, back care, accident prevention, and health fairs). Democratic companies were much more likely to have adopted health promotion programs. Reasons for having adopted these programs were related to containing health costs (40%), improving productivity and morale (25%), improving health (25%), and reducing absenteeism (5%). Reasons for not adopting programs had to do with not having enough time (60%), too much expense (30%), no interest by the employer (28%), and no interest by employees (25%). The authors conclude that authoritarian companies engage in 'old' forms of social control and tend to ignore the needs and wishes of their constituency. Democratic companies in contrast exercise 'new' forms of social control. That is, they encourage productivity and loyalty by listening to the constituency's expressed needs and provide opportunities that fulfill these needs. The kind of decision-making processes that institutions go through may have significant implications for their ability to choose and willingness to adopt and implement prevention programs.

Sections

Program Adoption, Implementation, and Maintenance

Bosworth, K., & Cueto, S. (1994). Drug abuse prevention curricula in public and private schools in Indiana. Journal of Drug Education, 24 (1), 21-31.

This paper is written for policy makers regarding the adoption of programs prior (1990) to the implementation (1991-92 school year) of mandated prevention programming in public schools in Indiana. This is four years after the initial implementation of the Drug-Free Schools and Communities Act (1986) which made funding available to schools to purchase programs.

Of interest beyond the distinctions made between public and private schools noted in the abstract, is the nature of the distribution of program adoption among both private and public schools. For elementary grades (K-6), commercial programs were adopted by 17.3% of private schools but 36.8% of public schools. In contrast, 34.5% of private schools had developed their own programs compared to 29.5% of public schools. Law enforcement programs were more common in private schools (16.5%) than in public schools (10.0%). (With the dissemination of DARE, law enforcement programs are much more common in the middle 1990s.)

For middle and junior high schools, commercial programs had been adopted by 46.6% of public schools and 39.8% of private schools; 35.5% of public schools claimed to have locally developed programs which was comparable to 29.3% of private schools; and few middle schools (1.1% of public, 5.3% of private) had law enforcement delivered programs. For high schools, public institutions were more likely than private to have adopted commercial programs (28.0% vs 18.2%) and have locally developed programs (47.7% vs 31.8%). Law enforcement programs were rare in high school (0.3% and 4.5%).

This article reported that schools were more likely to have trained staff delivering commercial programs than locally developed programs. Private schools were more likely to have trained teachers delivering programs than public schools.

These findings suggest that commercial and locally developed attempts at prevention were relatively common in schools even before local mandates required program adoption. There was theoretically great diversity in the programming available.

Dijkstra, M., de Vries, H., & Parcel, G. S. (1993). The linkage approach applied to a school-based smoking prevention program in The Netherlands. Journal of School Health, 63 (8), 339-342.

This article describes a model of augmenting the potential for programs to be adopted. The point of departure for this article is that many prevention programs fail to gain adoption. The attributed reason for this is that prevention program developers (the resource system), often researchers or expert consultants, do not understand the needs of practitioners (the user system). Users, therefore, often feel put upon when adopting programs that were not designed to fulfill their specific needs or to fit within existing systems. To overcome this challenge, the authors recommend the active development of a linkage system, individuals who can ensure that the needs of both groups are communicated and responded to. The linkage system is required to understand the needs and capabilities of both the resource and user systems. They recommend the involvement of individuals playing a linkage role from the outset of any prevention program development activity.

The case study that is examined involved researchers (the resource system), teachers (the user system), and district health educators (the linkage system).

The linkage system did not play a direct role in either program development or implementation, but served solely as a facilitating group. The collaboration process involved six steps: (1) an initial meeting to discuss the project and the process; (2) the development of an implementation manual; (3) recruitment of schools to participate; (4) a second combined group meeting to train implementers and resolve issues; (5) program implementation; and (6) program evaluation. (The activities in this process do not differ from those that would be completed without a linkage system; the difference is the degree of communication between developers and users that was generated.) In this example, both advantages and disadvantages were noted. The advantages were directly related to the goals of linkage: increased communication and willingness to adopt. There were also disadvantages: time requirements were taxing as were completing all required activities. However, all health educators reported a willingness to participate in another such trial. Success at achieving a diffusion of the program using this system was not tracked or reported and comparisons to any alternative model were not given.

Donaldson, S. I., Graham, J. W., Piccinin, A. M., & Hansen, W. B. (1995). Resistance-skills training and onset of alcohol use: Evidence for beneficial and potentially harmful effects in public schools and in private Catholic schools. Health Psychology, 14 (4), 291-300.

This article addresses a concern about the effectiveness of programs that address peer pressure resistance skills training. Schools throughout the Nation began developing and adopting programs that featured techniques for resisting peer pressure after the introduction of the "Just Say No" campaign of the Reagan era. Though based in part on promising findings from research programs, resistance skills training itself had not technically been isolated as the mechanism by which these programs worked. Nonetheless, the simplicity of the message and the ease of skill education seem to have made resistance skills training a component that has been adopted pro forma. This article points out that this highly touted method is not without its problems. Indeed, the approach was counterproductive. Once established, programs that taught students to say no to drugs became entrenched in the national thought processes about what constituted an effective program. Once institutionalized, explanations of why adolescents use drugs become fixed and are hard to change. Nonetheless, the adoption of ineffective approaches stands as a barrier to adopting and implementing effective programs. These findings suggest that less ideological approaches to solving social problems like drug use should be pursued.

Flannery, D. J., & Torquati, J. (1993). An elementary school substance abuse prevention program: Teacher and administrator perspectives. Journal of Drug Education, 23 (4), 387-397.

The authors of this article conclude that without teacher satisfaction with program materials and without perceived direct benefit to students (immediately observable outcomes rather than changes in risk and protection factors or changes in behavior), programs are not likely to be implemented. The effectiveness of any drug prevention program depends largely on satisfaction with and enthusiasm about the program. Even effective programs will fail if not adopted and implemented. The authors report that teachers reported more effectiveness of the program if parents were actively involved in implementation. Teachers' comments about the program suggested that (1) teachers' perceptions about potential benefit; (2) integration of activities into existing systems; and (3) ongoing training should be considered in order to maximize the potential for adoption and implementation.

Forrest, J. D., & Silverman, J. (1989). What public school teachers teach about preventing pregnancy, AIDS and sexually transmitted diseases. Family Planning Perspectives, 21 (2), 65-72.

This article primarily addresses sex education, but was included because it points out that social acceptability of programs is an important determinant of program adoption. Teachers noted that the pressures they faced from parents, from the community, and from school officials were the major barriers they faced to adopting and implementing an ideal program. Drug use, though less controversial, may in fact face many of these same constraints from parents, community groups, and administrators. Increasingly, there will be demands to link drug education and sex education programs to address the common issues of prevention that they share. Teachers also reported a lack of availability of good materials in this area (dated materials, uninteresting approaches, materials that were difficult to read). Most teachers (80%) reported they needed additional training and assistance with teaching content and methods.

Gingiss, P. L., Gottlieb, N. H., & Brink, S. G. (1994) Increasing teacher receptivity toward use of tobacco prevention education programs. Journal of Drug Education, 24 (2), 163- 176.

This study was designed to study the adoption and implementation of a Statewide program. In theory, all teachers to be surveyed had been sent curriculum materials. At the time of the survey, only 46% claimed to have received materials, suggesting that, at a minimum, the distribution of materials has its own set of problems. The number who intended to use the program by self-report exceeded those who actually implemented the program. Thus, in dissemination, there is likely to be a great deal of provider attrition.

The potential for program adoption can be partly explained given teacher and district characteristics. The predictors for initial implementation were slightly different than the predictors for maintained implementation. The strongest predictors of initial implementation were 1) personal involvement in tobacco prevention, including previous efforts at tobacco prevention and (2) perceived support for teaching tobacco prevention. On the other hand, the best predictors of continued implementation included 1) discussions with other teachers about tobacco prevention and 2) the perceived likelihood that they and other teachers were going to continue using materials in the following year. These findings suggest that the normative environment is an important determinant of program maintenance. In many ways, programs may be somewhat faddish, going in and out of popularity for reasons that are related to social reputation. Because personal involvement was a predictor of continued participation, it may well be that the link to maintaining a norm of implementation is to develop a critical state of involvement with any given program. A major strategy to overcoming barriers to adoption, implementation, and maintenance of effective programs may be to develop enthusiasm, loyalty, self-efficacy, and sufficient skill to implement the program right from the start.

Goldman, K. D. (1994). Perceptions of innovations as predictors of implementation levels: The diffusion of a nationwide health education campaign. Health Education Quarterly, 21 (3), 433-443.

This article reviews the adoption and implementation of a national March of Dimes campaign among 133 local chapters. The value of this article for drug abuse prevention is that (1) it focuses on community agencies and (2) the article discusses a program that in many respects may be similar in structure to some that address drug abuse. Adoption and implementation were evaluated using Rogers' five categories of perceived attributes (compatibility, complexity, observability, relative advantage, and trialability). Six dimensions were actually discovered (compatibility with needs, trialability, simplicity/complexity, relative advantage, observability, and compatibility with organization experience). The greatest predictor of program implementation was simplicity (r=.28). Observability (the ability of the organization to communicate about the intervention with others) was also an important predictor of adoption (r=.27). Compatibility with chapter needs (r=.22) and relative advantage (r=.19) were also significantly correlated but contributed less to understanding adoption and implementation. Trialability (the ability to stage the adoption of the intervention) and compatibility with prior organizational experience were not significant predictors of adoption and implementation. The article suggests that simple programs that have the ability to boost the visibility of a program are the most important characteristics for which program developers should strive if adoption and implementation goals are to be met. The need for a program and its potential effectiveness are important, but of secondary concern.

Griffin, G. A., Loeffler, H. J., & Kasell, P. (1988). Tobacco-free schools in Minnesota. Journal of School Health, 58 (6), 236-239.

This article summarizes the adoption of "Tobacco-Free Schools" initiatives in Minnesota. This project was developed and implemented by the American Lung Association of Minnesota. A manual describing the benefits of a school-wide policy for not allowing tobacco to be used on school property was developed. School districts were recruited and trained. The program realized significant adoption and implementation, increasing the proportion of schools that had tobacco-free policies from 3% to 43% over a one-year period. The article points to the potential to implement programs successfully on a broad scale with the support of an active nonprofit partner. In part, the success of the program can be attributed to the simplicity of the approach. Most schools simply banned smoking on campus by all students and adults.

Kaltreider, D. L., & St. Pierre, T. L. (1995). Beyond the schools: Strategies for implementing successful drug prevention programs in community youth-serving organizations. Journal of Drug Education, 25 (3), 223-237.

This article is written to benefit social planners who work with community-based organizations. Community organizations, particularly those not specifically dedicated to drug abuse prevention, have natural tendencies that interfere with the implementation of prevention programs once adopted. These tendencies include: (1) the voluntary nature of participation by the target population (teens in community organizations often only participate in activities they are interested in; making activities mandatory defeats the purpose); (2) the recruitment and retention of qualified staff (staff changes make continuity of the program a challenge); (3) conflict between the ideal and the practiced mission insofar as prevention is concerned (community groups may see the prime goal as social and exclude behavior or attitude change goals); and (4) tenuous and scarce funding. Strategies for circumventing these barriers include: (1) employing a team approach and making program institutionalization a goal; (2) choosing the "right" prevention program leader; (3) creating a special prosocial bonding group for program youths; (4) involving program graduates as recruiters and positive role models; and (5) developing community support. The authors cite their experience working with Boys and Girls Clubs in the Stay SMART program as a case study. Orchestrating these strategies needs to have high priority within the organization and serves as a challenge that must be continuously addressed.

Metsch, L. R., Rivers, J. E., Miller, M., Bohs, R., McCoy, C. B., Morrow, C. J., Bandstra, E. S., Jackson, V., & Gissen, M. (1995). Implementation of a family-centered treatment program for substance-abusing women and their children: Barriers and resolutions. Journal of Psychoactive Drugs, 27 (1), 73-83.

This article primarily addresses treatment issues. Thus, topics such as finding facilities and developing child care capabilities that are not common in prevention program implementation receive substantial emphasis in the paper. However, there are universal issues, including the recruiting, hiring, and training of staff, establishing and maintaining community linkage, and balancing the needs of intervention and research. That these issues appear to be barriers to the establishment of prevention programs as well suggests that they will be universally challenging to the implementation of any community-based intervention efforts. Prevention efforts need to address institutionalization concerns as an expected part of their design.

Nelson-Simley, K., & Erickson, L. (1995). The Nebraska "Network of Drug-Free Youth" program. Journal of School Health, 65 (2), 49-53.

This article reports a six-year implementation of a community prevention strategy that involves forming, training, and supporting local drug-free youth groups.

The long-term delivery of this program reflects Statewide (Nebraska) institutionalization of this effort. The authors attribute the duration of this effort to several factors including: (1) adult sponsors= willingness to devote volunteer time to maintaining the group and (2) follow-up support provided by State and regional professional prevention staff.

Orlandi, M. A. (1986). Community-based substance abuse prevention: A multicultural perspective. Journal of School Health, 56 (9), 394-401.

The primary hypothesis of this paper is that program adoption and implementation hinge on meeting general and specific standards that subgroups within communities apply when reviewing and implementing programs. Several general cultural issues are addressed. These issues include: language, reading level, models, hidden messages that reflect a different culture, motivational issues (control and manipulation), the selection targets that are outside the norms of the culture, stigmatization, blaming the victim, placing health promotion higher in value than it normally is within the culture, and entropy (the tendency to portray clients as powerless). Additional specific issues for African American, Hispanic American, Asian American, and Native American subgroups are presented. The implications for designing interventions that can receive better adoption and implementation among subgroups involve (1) being aware of the cultural source from which programs were developed; (2) completing pilot testing with specific subgroups; and (3) using a model of program development that either starts from the culture itself or actively involves linkages to create a dialogue between program developer and users. Such approaches should overcome barriers that currently exist to program adoption and implementation.

Parcel, G. S., Simons-Morton, B. G., & Kolbe, L. J. (1988). Health promotion: Integrating organizational change and student learning strategies. Health Education Quarterly, 15 (4), 436-450.

This article addresses school-based problem behavior prevention and health promotion programs from a community organization perspective. Rather than simply seeing the school as an outlet for curricular interventions, the paper proposes that schools be viewed as having multiple elements and functions (health service delivery, education, an environment, community linkages, physical education and sports, food service delivery, counselling, and mentoring). A major strategy for overcoming the failure to adopt a specific programmatic effort is the mobilization of the entire organization with organization change as a major focus of intervention. Among the other goals of organization development is advancing readiness for change. Readiness is proposed to develop in an ordered set with (1) institutional commitment preceding (2) alterations in policies and practices which in turn precede (3) alterations in the roles and actions of staff and which finally result in (4) student learning activities. Activities devoted to each of these readiness factors have the potential to break down barriers to the adoption and implementation of prevention programming.

Paulussen, T. G.W., Kok, G. J., & Schaalma, H. P. (1994). Antecedents to adoption of classroom-based AIDS education in secondary schools. Health Education Research, 9, 485- 496.

This article is an attempt to conceptualize the decision-making process that underlies the adoption of AIDS education programs in the Netherlands. The investigators considered a model derived from the Theory of Planned Behavior as the basis for predicting program adoption. Thus, there were four variables defined as related to the interactive context (school policy, collegial interaction, perceived consensus, and descriptive norms), five variables that identified a teacher's general disposition (student-centeredness, perceived personal responsibility, stability, perceived controllability, and attitudes about sexual morality), and three variables related to belief about adoption (outcome beliefs, subjective norms about AIDS education, and self-efficacy to delivery programming). Determinants of intended adoption of an AIDS education program included subjective norms, self-efficacy, outcome beliefs, formal school policy, perceived personal responsibility, collegial interaction about the topic, and a belief in sexual morality. These findings suggest that specific organizational characteristics and personal characteristics have a significant impact on the adoption process. Each of the identified predictors represents a modifiable issue that, if improved, may increase the likelihood of program adoption.

Paulussen, T., Kok, G., Schaalma, H., & Parcel, G. S. (1995). Diffusion of AIDS curricula among Dutch secondary school teachers. Health Education Quarterly, 22 (2), 227-243.

Awareness of four AIDS prevention curricula that were being disseminated among Dutch secondary school teachers was a function of direct advertising (60% had received publishers' overviews or direct mail solicitations, 34% had discussed the curriculum with a colleague, 63% knew someone else using the curricula). Only 16% had personal communication with external consultants about the curriculum they were planning to adopt. A critical finding from this study is that teachers= reliance on norms (what others are doing) and perceived practical implementation potential was important. The potential to produce changes in behavior was not considered to be important. Ergo, adoption of programs is often based on what is popular and what is easy to implement rather than on what will work.

Rohrbach, L. A., Graham, J. W., & Hansen, W. B. (1993). Diffusion of a school-based substance abuse prevention program: Predictors of program implementation. Preventive Medicine, 22 (2), 237-260.

This article reports on an attempt at school-based program dissemination that featured teacher training under conditions of additional intervention with the principal versus training without additional principal intervention. Training was either standard or intensive. Maintenance of the program was severely reduced during the second year of the project. Two types of variables predicted maintenance: (1) the characteristics of teachers delivering the program and (2) the presence or absence of an intervention that was designed to promote support of the program among the schools= principals. Those who continued to deliver the program were newer to the teaching profession, had received more training in interactive methods, felt more comfortable and confident about their ability to teach using interactive methods, and had greater initial enthusiasm for the program. Principal support for the program predicted both the implementation of the program and the quality of teaching that was delivered.

Smith, D. W., McCormick, L. K., Steckler, A. B., & McLeroy, K. R. (1993). Teachers' use of health curricula: Implementation of Growing Healthy, Project SMART, and the Teenage Health Teaching Modules. Journal of School Health, 63 (8), 349-354.

This study was specifically designed to test dissemination of tobacco prevention programs that had been previously shown to be effective: Project SMART, Growing Healthy, or the Teenage Health Teaching Modules. In the design, teachers in experimental districts were offered one of the three curricula and, in addition, were offered training. In the control districts, curricula were made available but training was not offered. Teachers were followed during the initial year (immediately after the offering) and at one year. At each point, implementation of the program was assessed and, if implemented, completeness of implementation was also assessed. Training and the presence of a health education coordinator in the district were important predictors of implementation of the curricula during the initial year (implementation) and became even more important predictors during the subsequent year (maintenance). The presence of a supportive principal or other administrator was not important during the initial year. However, a supportive principal became very important for maintenance; teachers who did not have support stopped teaching the program. Finally, the complexity of the curriculum that was taught was an important predictor of the completeness with which the program was taught. The most complex program, Teenage Health Teaching Modules, received far less implementation than the other two. The authors attribute this both to the relatively shorter time requirements of Project SMART and Growing Healthy and to the more familiar classroom-based format of the latter programs. Training and support are important incentives that can clearly aid in the dissemination of effective prevention programs and practices.

Smith, D. W., Redican, K. J., Olsen, L. K. (1992). The longevity of Growing Healthy: An analysis of the eight original sites implementing the School Health Curriculum Project. Journal of School Health, 62 (3), 83-87.

This paper reports about the School Health Curriculum Project, an innovative health and prevention curriculum that is delivered to students in fourth through seventh grades. The School Health Curriculum Project was developed in the late 1950s and early 1960s and eventually disseminated to schools in the late 1960s. This study examines the longitudinal institutionalization of the School Health Curriculum Project in eight school districts that had adopted the program in 1969. (The date of the survey is not presented in the article which was published in 1992. Presumably the survey occurred circa 1990.) Two of the eight sites continued to implement the School Health Curriculum Project. Two sites had materials available to teachers but were not actively implementing the project. The remainder had discontinued its use. Multiple reasons for discontinuation were given, including (1) lack of funds; (2) lack of trained personnel and continued training and support; (3) lack of organizational support in the school and district; (4) lack of commitment to the program; and (5) the adoption of competing programs that were perceived to be more effective. The authors conclude that long-term maintenance of a program requires several conditions, including the presence of a program champion who has enthusiasm about a program and the power to maintain its place. The authors also place an emphasis on routinely providing information to the community about the needs for and benefits from adopted programs. Often, once adopted, the social marketing of a program stops, allowing competing interests (both those related to and those not related to prevention) to surface and compete. The authors warn that deinstitutionalization of a successful program can have serious long-term effects on the motivation to reinstitutionalize other programs.

Tricker, R., & Davis, L. G. (1988). Implementing drug education in schools: An analysis of the costs and teacher perceptions. Journal of School Health, 58, 181-185.

This paper addresses implementation of a widely disseminated prevention program, Here's Looking at You, II (Districts A and B) and a second less-widely disseminated program, Starting Early (District C), from the perspective of financial expenditure and resource availability. The costs expended for the program were calculated on a per-district level. The costs in District A were $45.00 per hour for teaching, in District B were $22.03 per hour and in District C were $13.60 per hour. In addition, for Here's Looking at You where program materials are shared among teachers, the ratio of materials sets to teachers was calculated. In District A the ratio was 7:1, in District B the ratio was 3:1. District C teachers were fully supplied with materials. District A teachers were less likely to implement the complete program (56%) than District B teachers (91%) or District C teachers (91%). District C teachers felt less positive about quality than District A and B teachers; 60% of District C teachers felt the program to have quality compared to 100% of District A and B teachers. These findings suggest that there is a complex mix between program quality and implementation quality. District A teachers were nearly under-supplied with materials despite District A spending more money on the program per teacher. This resulted in considerably less implementation of the program. District C teachers, who were fully supplied with materials (and at a comparatively reasonable cost) were less likely to continue the program because they viewed materials to be less than adequate. District B teachers were, in the end, more satisfied with the mix of program materials and program quality and benefitted from lower overall costs than teachers in District B. This paper's contribution to the field is an innovative method for assessing adoption and implementation from a cost-to-benefit perspective.

Sections

Achieving Effectiveness

Basen-Enquist, K., O'Hara-Tompkins, N., Lovato, C. Y., Lewis, M. J., Parcel, G. S., & Gingiss P. (1994). The effects of two types of teacher training on implementation of Smart Choices: A tobacco prevention curriculum. Journal of School Health, 64 (8), 334-339.

The authors intended to discover the importance of and viability of face-to-face versus videotaped teacher training as a means of encouraging schools to implement prevention programs. Smart Choices, the program implemented in this study, was developed originally as the Minnesota Smoking Prevention Program and renamed by the State of Texas. The authors note four phases of diffusion: dissemination, adoption, implementation, and maintenance (also noted by others in this bibliography). The project focuses on implementation with a specific focus on use, completeness of delivery, and fidelity of delivery. In this case, use was not actually measured and not all teachers who were trained returned questionnaires. Completeness referred to teaching from all sessions. Fidelity referred to teaching using called-upon methods (brainstorm, active use of peer leaders, the use of small groups, and student role playing/presentations). Statistical differences demonstrated face-to-face training to be statistically superior for brainstorming and role plays/presentations, and also marginally superior for the use of peer leaders. There was no observation in this study. Typically fidelity refers to more than simply using methods, it also expands to include following the intent of a session and achieving short-term goals related to mediating variables. Thus, fidelity was only partly measured. Training may remain a significant barrier to the implementation of theory-based programs. The authors note that, while videotape-based training has the potential benefit of making training available upon demand, the drawbacks that may consistently attend such efforts will be poorer quality implementation. Most research-based and effective programs require the adoption of novel teaching methods and teaching about concepts that are different than those which many implementers will be prepared to address.

Bosworth, K., & Sailes, J. (1993). Content and teaching strategies in 10 selected drug abuse prevention curricula. Journal of School Health, 63 (6), 247-253.

This article is framed by contrasting the state-of-the-art in prevention programming against a background of the traditional pedagogy of teaching (lecture, rote memorization, and textbook-driven course work) that is the foundation of the public educational system. The primary concern of this paper is that teachers are likely not to have the background in teaching methods that state-of-the-art programs require in order to be implemented with fidelity. The article reviews observational research demonstrating that even among teachers well-trained in a curriculum's methods, many fail to be able to perform critical elements such as role plays adequately. The authors identify seven nontraditional (not lecture or seat work) strategies used to some degree in each of the reviewed curricula: (1) brainstorm; (2) full-class discussion; (3) games; (4) homework requiring interaction with parents; (5) media analysis; (6) role play; and (7) small group work or cooperative learning. The most interactive methods (brainstorm, games, role play, and small group/cooperative learning) made up approximately one-third of the activities in reviewed curricula.

Conclusions of the analysis noted that no two curricula shared the same balance in methods or emphasis C a generic training program in methods may not be possible and training may always need to be tied to a specific program. Nonetheless, the clear movement away from lecture will put strain on the educational system by introducing methods that many teachers are unfamiliar with. Training as currently configured may be insufficient to develop needed skills in teachers. Further, there was great variability in the degree to which the written programs provided details needed to implement interactive elements; some programs provided sufficient detail, others did not. The assumptions about content and method found in highly interactive programs may cause teachers to abandon the program or to deliver it with no greater impact than ineffective programs.

Gingiss, P. L. (1992). Enhancing program implementation and maintenance through a multiphase approach to peer-based staff development. Journal of School Health, 62 (5), 161-166.

Even though the title and abstract of this article discuss implementation and maintenance, this article also addresses understanding how to achieve effectiveness in implementation. The author discusses the challenges that innovative psychosocial programs present to the educational system in terms of teacher capability for performance. Five basic premises are presented:

(1) teachers respond to innovations in developmental stages; (2) a multiphase approach to staff development is necessary to assist teachers during each stage; (3) post-inservice staff development requires opportunities for teacher collaboration; (4) approaches to staff development should fit the stage of teacher development (skill level); and (5) the organizational context of staff development is critical. Peer-based approaches to post-inservice staff development include professional dialogue, participation in curriculum development and school improvement, observation and assessment, supervision by peers or clinical trainees, peer coaching, and action research that requires data collection and analysis in applied settings. School climate, leadership, and policies that promote staff development are crucial for success. An important insight presented by the author is that teachers need to be able to adapt innovations to meet the needs and abilities of their students. Such adaptations require a higher-order understanding of content. In such a context, simply providing training about written methods is clearly insufficient to produce desired effects. Collaboration among teachers, dialogue with professionals outside the immediate sphere, and being observed and receiving feedback are all recommended strategies for overcoming barriers to effective program delivery.

Goodman, R. M., Wheeler, F. C., & Lee, P. R. (1995). Evaluation of the Heart to Heart Project: Lessons from a community-based chronic disease prevention project. American Journal of Health Promotion, 9 (6), 443-455.

Heart to Heart was an attempt to replicate elements of the Stanford Five Cities Project, the Minnesota Heart Health Project, and the Pawtucket Heart Health Program in a small community for significantly less money. The three example projects were funded to be highly community oriented but were research-based efforts that received large amounts of funding. CDC funded a local health department without the direction of expert researchers to model activities and programs after those developed by these larger projects. The project had a slightly favorable intervention effect on cholesterol and smoking but failed to have an effect on other risk factors for cardiovascular disease. The project influenced community awareness, enlisted influential community members, and fostered linkages among local health services. A major goal of dissemination is to produce the same kinds of effectiveness results in replication projects that were produced in original research projects. This article concludes that such outcomes will be challenging to produce. The authors attribute some of this failure to level of funding. However, comparing replication and prototype programs, there was also less expertise available to the replications both in terms of design and execution. The replication examined here only modeled program components; it did not intend to replicate the original project in its entirely. Drug prevention programs developed and implemented by research may face the same end; implementation subsequent to prototype testing may fail to measure up to the effectiveness that many prevention programs are found to have in randomized field trials.

McIntyre, L., Belzer, E. G., Manchester, L., Blachard, W., Officer, S., & Simpson, A. C. (1996). The Dartmouth Health Promotion Study: A failed quest for synergy in school health promotion. Journal of School Health, 66 (4), 132-137.

This article examined enhancing effectiveness through coordinated versus stand- alone program delivery. The qualitative findings point to the fact that the coordinated approach was well-received by key players. However, there were no increases in effectiveness as measured by outcomes. The potential value of integrating, not tested here, is the potential durability of a program after its experimental stage. However, it is important to remember that awareness and acceptance are not impact. It is likely that in many practitioners' eyes, awareness and acceptance are confused with the potential of a program to prevent the onset of drug use; popular programs that are ineffective are likely to be thought of as effective despite any evidence to the contrary.

McLaughlin, R. J., Holcomb, J. D., Jibaja-Ruseth, M., & Webb, J. (1993). Teacher rating of student risk for substance use as a function of specialized training. Journal of Drug Education, 23 (1), 83-95.

The purpose of this article is to encourage training in diagnostic criteria for identifying students at risk for substance use. The benefit of such training, theoretically, is that once teachers can identify high-risk students, they may then be able to provide special attention to and special programs for these students. This has the long-term potential of making prevention efforts more successful when delivered in typical settings. Training in this project improved the identification of high-risk students. However, based on self-report measures, there were still many students who were not correctly identified as high-risk and some students who were not high-risk were identified as being high-risk (Type I errors). Being efficient at identifying risk status and applying interventions has not yet been researched. However, it is assumed that diagnostic ability would aid in programs being delivered more effectively.

Taggart, V. S., Bush, P. J., Zuckerman, A. E., & Theiss, P. K. (1990). A process evaluation of the District of Columbia "Know Your Body" project. Journal of School Health, 60 (2), 60-66.

This article reports on an outcome evaluation of the Know Your Body program as implemented in the District of Columbia that includes an emphasis on process evaluation. Of primary interest are findings relating to the quality of program implementation. From teacher observation data, a broad distribution of quality of implementation was observed. Teachers' personal habits were noted (a sizable minority smoked and many 'appeared' overweight). Overall, teachers who were judged to have higher quality implementation had more favorable outcomes. There are weaknesses in this write-up that make the information presented less convincing than it should be. No correlation, regression, or inferential statistics are presented. Even though the conclusions made by the paper are that teacher characteristics and implementation fidelity were important for outcomes, the linkage between the two is not demonstrated.

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