1. Sustainability of Prevention Programs and Initiatives: A Community Building Framework
Suzanne Spear, Lawrence A. Palinkas, Sapna Mendon, Juan Villamar, and C. Hendricks Brown

2. Grants: NIDA R34DA037516 & NIDA P30DA027828
Acknowledgements
Grants: NIDA R34DA & NIDA P30DA027828

3. Acknowledgements Center Dir. Frances Harding, CSAP
Center for Substance Abuse Prevention (CSAP)
Division of Community Programs
Division of State Programs
Center for Mental Health Services (CMHS)
Division of Prevention, Traumatic Stress, and Special Programs

4. Disclaimer
The views, opinions and content expressed in this presentation do not necessarily reflect the views, opinions or policies of the Center for Mental Health Services (CMHS), Center for Substance Abuse Prevention (CSAP), the Substance Abuse and Mental Health Services Administration, or the U. S. Department of Health and Human Services (HHS)

5. Phase 1 of Measuring Sustainment of Prevention Programs & Initiatives
Study Aim:
Identify core components and their interrelationships across time for sustainment of prevention programs and their support infrastructures

6. SAMHSA Ce-PIM Partnership
Four SAMHSA Prevention Programs:
Strategic Prevention Framework State Initiative Program (SPF-SIG)
Drug-Free Communities Support Program (DFC)/Sober Truth on Preventing Underage Drinking (STOP Act)
Garrett Lee Smith State and Tribal Youth Suicide Prevention (GLS)
Implementing Evidence-Based Prevention Practices in Schools (PPS)

7. Current Conceptual Models of Implementation
Originated in health services research field
Based on implementation & behavioral theories, e.g., DOI, Theory Planned Behavior
Sustainment is understood as final stage in a linear process

8. Current Conceptual Models of Implementation
Main predictors are characteristics of innovations and individual actors (innovation users, champions, trainers)
Unit of analysis is an organization, e.g., health clinics
Little to no emphasis on communities

9. Community Coalition Approach to Prevention
Coalition-based approach uses the principles of community engagement, local problem solving, and population-based approaches to improving health and quality of life. Coalitions are a primary mechanism for involving broad group of stakeholders. The coalition- approach emphasizes the importance of cross-sectoral collaboration.
SAMHSA’s SPF focuses on capacity development, helping communities develop “community prevention systems to identify and respond to community needs.” The theory is that organizational and infrastructure development builds capacity to implement programs and then sustain them.
SAMHSA is not just interested in sustaining programs but also prevention processes

10. Measuring Sustainment of Prevention Programs Study
Phase 1
Telephone interviews and site visits with 10 grantees
Interviews with 45 key staff.
Collection of grant proposals, progress reports, other documents.

11. Methods
Data analysis
Analyzed qualitative data (interviews & free lists)
Data were coded & organized into common categories/domains
Frequency of categories observed for free lists
Most common categories on free lists compared with those from the interviews
Domains were used to construct a set of broad themes

12. Theme 1- Thinking Big: Broadening the Lens of Sustainability
The focus of all grant programs is the community
Goals of SPF-SIG, STOP-ACT, & GLS are broad, e.g., improving prevention systems, coordination of care across providers, and changing social norms
Developing relationships & strengthening coalitions just as important for sustainment (and sometimes more important) as interventions

13. Theme 1- Thinking Big: Broadening the Lens of Sustainability
“…One of the things, one of the outcomes, which is not necessarily an outcome about behavior, but about infrastructure was the Berkshires had developed a coalition...That was one of the objectives for that grant, was to actually have the Berkshires develop a self-sustaining suicide prevention coalition. You can almost think of it as a statewide coalition of sorts, because if you don’t have that investment by multiple agency partners, you’re not going to get it moving, and not going to keep it sustaining, because we all have to talk the same language.” (GLS grantee from MASS)

14. Theme 2- Improving Prevention through Community Building and Capacity Development
Prevention practices and processes are mutually reinforcing.
Capacity development (i.e., training & technical assistance, program/coalition coordinator) is critical for changes at community or system level.
SAMHSA’s planning framework emphasizes the role of infrastructure in improving community health

15. Theme 2- Improving Prevention through Community Building and Capacity Development
“If we’re doing our job, we don’t want them to do the same media campaign for 100 years. So we want to give them the capacity to use data, to pick the appropriate intervention for whatever intervening variable [or] contributing factor…I think prevention is going to be stronger. That to me, is what I would hope would be sustained, and that’s what I was tasked to do to work with communities to make that happen.” (Evaluator for SPF-SIG grant)

16. Theme 3: Sustainment as Dynamic, Emergent Process
Support for sustainment of a particular program or intervention must be actively cultivated by strong leaders within community coalitions and networks (e.g., need “buy in”)
Outcomes for many programs do not yet exist; hence importance of evaluation
Community building can develop a shared consciousness around the importance of programs and initiatives

17. Theme 3: Sustainment as Dynamic, Emergent Process
Suicide prevention expansion requires a shared consciousness or “culture of prevention” :
“The Zero Suicide philosophy is that suicide is a thing that is preventable and that we have all have a responsibility to do so and that it’s not a tangential service of mental health care but it is a primary service and should be, if nothing else, the first thing we address whenever we work with any client.” (GLS grantee TENN)

18. Community-Building Framework for Sustainment of Prevention Programs
Key Principles
Community is at the center of practice.
Community defined as relations between people & organizations at multiple levels (local, region, state) (Walter, 2006).
Community is dynamic, emergent, created and recreated through actions & interactions of people & organizations (Walter, 2006).

19. Community-Building Framework
Key Principles, cont.
Goal is to develop capacity of community to identify, mobilize & address social and public health problems (Goodman et al., 1998)
Programs should incorporate & build upon community strengths (Wallerstein et al., 2015)
Process & outcomes are inseparable (Walter, 2006)

20. Comparison of Health Services and Community-Building Frameworks for Sustainment
Features
Health Services
Community-Building
Definition Sustainment
Final stage of process
Strong community capacity to assess needs, plan programs, and evaluate
Goal of Sustainment
Sustain programs and interventions long-term
Build community capacity to identify and solve its problems
Unit of Analysis
Individual, organization
Community
Contextual Features
Patient needs and resources, organizational climate, policy and funding support
Community needs and strengths; partnerships, coalitions, and networks; policy and funding support
Focus of Capacity Building
Organization
Community coalitions
Sustainment Strategies
Individual and organizational change in favor of adoption and implementation of practices
Build community capacity to identify needs, solve problems, create systems change

21. Community-Building Framework of Sustainment of Prevention Programs
Community-Building Strategies
Organize coalitions (local, regional, state)
Build community capacity (training, TA, coalition coordinator)
Develop personal relationships with key people in multiple agencies
Identify coalition “champions” to expand and strengthen coalitions
Develop shared consciousness about prevention practices
Community Factors
Local needs & resources
Individuals & organizations
Political & economic contexts
Extra-Community Factors
Funding sources
Technical assistance
Research & evaluation support
Policy support
Sustainment of Practices and Processes

22. Conclusions
Community context is important to implementation and sustainment of prevention programs
Building community and community capacity is central to improving health outcomes and sustaining programs
Sustainment is dynamic, an ongoing process of empowering communities to take action and building consensus around the need to sustain a practice