Abstract CN11-03: Designing sustainable cancer prevention interventions for populations of low socioeconomic status
Authors: Bennett Gary G. 
Published: May 2012

Abstract
Community-based cancer prevention interventions hold great promise in reducing the disproportionate cancer burden borne by populations of low socioeconomic status (SES). Indeed, use of community-based research approaches, particularly when combined with participatory principles (e.g., partnering with community members during each stage of the research process) may facilitate the development of intervention solutions that are better matched to particular community needs, priorities, and values. Though participatory strategies offer undeniable benefits for intervention design and implementation, it remains largely undetermined whether such approaches can similarly promote the dissemination of sustainable intervention approaches. Sustainability here refers to the organizational capacity to maintain an intervention implementation over time, in a fashion that preserves intervention efficacy. Barriers to intervention sustainability are widespread and prevalent across the socioeconomic spectrum. However, a prescient challenge is that while low SES populations remain in great need of intervention attention, the sustainability of evidence-based interventions is challenged by the resource constraints common among community-based organizations. Nevertheless, intervention sustainability remains a major area of emphasis for academic and community partners alike, although specific strategies that can be leveraged to achieve intervention sustainability in resource constrained settings remain elusive.
Many have suggested that achieving intervention sustainability may require systemic organizational change so that an organization's infrastructure and operations can be aligned with the intervention's design. From a pragmatic perspective however, such organizational change efforts may not be readily implementable, expedient, or even possible among resource-constrained community-based organizations. Rather, to be sustained in such settings, intervention designs likely need to match an organization's existing structure. To aid the planning process, we sought to create a straightforward, practical strategy that would be useful in guiding sustainability planning during intervention design. Our presentation will introduce the resulting framework, which identifies three mutually reinforcing factors, emerging from disparate disciplines that are major drivers of intervention sustainability in community settings: suitability, scalability, and returns. As an exemplar, we will discuss the sustainability planning efforts undertaken with our community partners on Shape, an obesity prevention intervention study for low SES, overweight women in a network of community health centers.
Many interventions - even those developed using participatory principles - are unlikely to be suitable for delivery over time at scale. Determining intervention suitability requires attention to several components that, in sum, reflect an intervention's fit with an organization's structure and strategic mission. Consideration of these structural (e.g. innovation-task fit, organizational capacity, presence of supportive policies, implementation climate) and strategic (e.g., leadership support, innovation-values fit) factors can facilitate the design of interventions that best accommodate the community organization's specific capabilities. With strong organizational leadership support for disease prevention, Shape was designed to fulfill the community health center's mission to address its entire population, including those without chronic comorbidities. Further, major changes were made to the original staffing and implementation plans to match intervention tasks with the health center's existing human and organizational resources. New innovations languish unless they are capable of accommodating user demand without compromising the consistency of implementation. The manner in which startup software companies plan for sustainability offers a useful analogue, as many of these organizations have developed strategies to scale their innovations despite limited resources. Several of these scalability principles (e.g., choice of delivery modality, load balancing, scalable parallelism, economies of scope) are useful to consider in the sustainability planning process with community partners. A major issue concerns whether scalability is achieved vertically (e.g., by increasing an organization's capacity to offer an intervention within one of its core offerings) or horizontally (e.g., by strategically increasing the organization's core offerings to include the intervention). Just as in the software industry, many existing community interventions are designed for vertical scalability, which may be appropriate in some circumstances, but can lead to decreased efficiencies and increased costs. Horizontal scalability is a more robust approach but requires a suitable organizational structure. The Shape study has been able to take advantage of structures that permit horizontal scalability planning. Staff was re-tasked to form a coordinated unit for the long-term delivery of Shape other similarly structured interventions. Computing systems have been collaboratively developed (and integrated with existing systems) in a manner that is robust enough to be utilized for the delivery of Shape and other interventions post study completion. Finally, most intervention content is distributed via telephonic application that provides economies of scope/scale and high delivery capacity.
The issue of organizational returns for intervention implementation has been cast largely in terms of cost-effectiveness. While cost-effectiveness is undoubtedly an important consideration, it may be less relevant for resource-deprived community organizations. Costs may be a major barrier to intervention sustainability, independent of intervention effectiveness. Related, the benefits of a given intervention (e.g. cost savings, productivity, reductions in sickness absence, longevity) may accrue to parties other than the community organization itself. Interventions need not always be self-sustaining (i.e. cost neutral), but in most cases clearly identifiable, though not necessarily financial, returns to the community organization are useful in advancing sustainability planning. We consider returns to be financial (e.g. direct payments, reimbursements, facilities and administration costs, economies of scale) or non-financial (e.g. staff training, staff task diversity, mission fulfillment, experience economy) benefits that accrue directly to a community organization as a result of implementing a given intervention. Shape was specifically designed to provide several short-term non-financial returns (e.g. increased staff morale via increased task diversity, staff training, experience economy), with the prospect of generating future financial returns.
Throughout the presentation, we will utilize data from published/ongoing community trials and case examples to highlight ways in which the participatory intervention design process can be augmented by attending to intervention sustainability. We will also demonstrate how the framework is fully complementary with leading intervention planning and evaluation approaches. Finally, we will highlight several questions and methodological considerations that are in need of greater research attention.
Citation Information: Cancer Prev Res 2010;3(1 Suppl):CN11-03.