An July 2019 article in BMC Public Health underlines the need for greater clarity when we discuss scaling up programs as opposed to more effective ways to implement an effective program. "The implementation of interventions at-scale is required to maximise population health benefits. ‘Physical Activity 4 Everyone (PA4E1)’ was a multi-component school-based program targeting adolescents attending secondary schools in low socio-economic areas.An efficacy trial of the intervention demonstrated an increase in students’ mean minutes of moderate-to-vigorous physical activity (MVPA) per day and lower weight gain at low incremental cost.This study aims to assess the effectiveness and cost effectiveness of a multi-component implementation support intervention to improve implementation, at-scale, of the evidence based school physical activity (PA) practices of the PA4E1 program. Impact on student PA levels and adiposity will also be assessed, in addition to the cost of implementation." A cluster randomised controlled trial, utilising an effectiveness-implementation hybrid design, will be conducted in up to 76 secondary schools located in lower socio-economic areas across four health districts in New South Wales (NSW), Australia.Schools will be randomly allocated to a usual practice control arm or a multi-component implementation support intervention to embed the seven school PA practices of the PA4E1 program. The implementation support intervention incorporates seven strategies including executive support, in-School Champion, teacher training, resources, prompts, audit and feedback and access to an external Support Officer. The primary trial outcome will be the proportion of schools meeting at least four of the seven physical activity practices of the program, assessed via surveys with Head Physical Education teachers at 12 and 24-months. Secondary outcomes will be assessed via a nested evaluation of student PA and adiposity at 12-months (Grade 8 students) and 24 months (Grade 9 students) undertaken in 30 schools (15 per group)" . ISHN Commentary: This promises to be an excellent study but will it measure the effect and cost effect of an implementation strategy as opposed to different methods for scaling up the multi-intervention program to other schools or other regions? Read more....

(An item from the ISHN Member information service)  The implementation, scaling up, maintenance and sustainability of individual programs as well as multi-intervention approaches such as comprehensive school health promotion requires new frameworks and better ways to understand the complex interactions at multiple levels in several systems. An article in Issue #5, 2015 of Prevention Science helps us toward that goal, as it describes the implementation and sustainability of a Social-Emotional Learning program in four schools in Wales. "his paper draws upon Rogers (2003) Diffusion of Innovations Theory to explain the adoption, implementation and discontinuance of a SEL intervention. A pragmatic, formative process evaluation was conducted in alignment with phase 1 of the UK Medical Research Council’s framework for Developing and Evaluating Complex Interventions. Employing case-study methodology, qualitative data were generated with four socio-economically and academically contrasting secondary schools in Wales implementing the Student Assistance Programme. Semi-structured interviews were conducted with 15 programme stakeholders. Data suggested that variation in implementation activity could be largely attributed to four key intervention reinvention points, which contributed to the transformation of the programme as it interacted with contextual features and individual needs. These reinvention points comprise the following: intervention training, which captures the process through which adopters acquire knowledge about a programme and delivery expertise; intervention assessment, which reflects adopters’ evaluation of an intervention in relation to contextual needs; intervention clarification, which comprises the cascading of knowledge through an organisation in order to secure support in delivery; and intervention responsibility, which refers to the process of assigning accountability for sustainable delivery." Read more>>

(An item from the ISHN Member information service)  An article in Volume 76, 2015 of Preventive Medicine reports on a review of studies using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate physical activity interventions aimed at youth. "A systematic search for controlled interventions conducted within the last ten years identified 50 studies that met the selection criteria. Based on Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance criteria, most of these studies focused on statistically significant findings and internal validity rather than on issues of external validity. Due to this lack of information, it is difficult to determine whether or not reportedly successful interventions are feasible and sustainable in an uncontrolled, real-world setting. Areas requiring further research include costs associated with recruitment and implementation, adoption rate, and representativeness of participants and settings. This review adds data to support recommendations that interventions promoting physical activity in youth should include assessment of adoption and implementation issues". Read more>>

(From the ISHN Member information service) An article in the June 21, 2014 issue of The Lancet calls for systems thinking from governments and Un agencies when they decide on the set of goals to replace the existing MDG goals. The authors assert that "Global priorities have progressed from the Millennium Development Goals (MDG) that will expire in 2015 to global sustainable development. Although there is not yet a consensus on the specific goals for the post-MDG era, the post-2015 investment agenda for health will probably emphasise social determinants of health, sustainable development, non-communicable diseases, health systems strengthening, universal health coverage, the health of women and children, and ageing."  They then go on to make the case for "systems thinking". " The MDGs were undoubtedly successful in focusing international donor financing and domestic investments to achieve the targets set in these goals. Yet, undue emphasis on financing narrow disease programmes used to achieve disease-specific targets in the MDGs often missed opportunities to effectively strengthen health systems.1 Consequently, several low-income countries with weak health systems have struggled to reach the targets set in health-related MDGs and will not achieve them by 2015.2 An important lesson from the MDGs is that current and emerging global health challenges require action that embraces interdisciplinary and intersectoral approaches to development,3 which acknowledge the path-dependence and context-dependence of implementation." 
A table in the article underlines the differences between "selective approaches" (linear thinking) focused on preventing specific problems and "systems thinking" In linear thinking, the program is developed from a blueprint, developed by trials in controlled circumstances, that are top-down in nature, often without considering local contexts or potential unintended consequences. In systems-based approaches, learning and context drive the action and selection of issues to be addressed as well as the programs. In linear thinking, the programs target disease-specific, quick-wins. Planners develop a specific program for a specific population and assess its ability to produce specific short-term outcomes. In systems-based approaches, the action is across various sectors, with key stakeholders involved from the beginning to develop and implement approaches across the relevant sectors. In selective thinking, there is a reliance on isolated, quantitative measures. Single snap shot data points are used by specialized experts to assess if the programs are meeting their objectives. In systems thinking, multiple interative measurements and synthesis as well as relationships are used to assess progress. Longitudinal, real-world data from multiple qualitative and quantitative sources are used to monitor relevant effects.  Read more>>      

(An item from ISHN Member information service) Scaling up (or diffusing innovations) is a major issue among others related the implementation/operation, capacity-building and systems change. The issue is discussed in an article appearing in Issue #6, 2012 of the International Journal of Education Development. The authors suggest that "Scaling-up their initiatives successfully and sustainably can be an efficient and cost effective way for NGOs to increase their impact across a range of developmental outcomes, but relatively little attention has been paid in the education sector to how best this may be done and debates appear to have stalled. One approach to scaling-up is replication, on which this paper focuses. While there is no one universally applicable path through which an educational NGO can achieve successful replication, more can be done to support choice of the best path to follow, with respect to specific NGO circumstances and the context within which it operates – and hopes to operate in future. This paper presents four known paths to replication alongside new illustrative diagrams to explore their advantages and disadvantages, and highlights the need for a fifth approach that does not appear in current literature. ‘Network replication’ is proposed as new pathway that draws on known strengths of networks and offers a learning-oriented approach to scaling-up".  Read more.