- Research is too seldom tested with realistic expectations of the staff resources and other organizational infrastructure of future adopters: The research staff training, time, and/or resources are often greater than what resource-constrained public health practice settings can muster. (We would also frame this issue as a failure to test programs with representative staff and delivery conditions, including the use of unrepresentative levels of supervision, feedback, and measurement.)
- Research is too seldom tested with representative participants. Participants are often less diverse than in the real world, in terms of both the spectrum of healthy and diseased individuals as well as the cultural, demographic, and health literacy differences that may influence program effectiveness.
- Research interventions are highly controlled and inflexible to local site adaptation