Translational Research in Action: Implementation of the Communities That Care Prevention System in 12 Communities

There is evidence from randomized, controlled evaluations and other research trials that problem behaviors can be prevented by preventive interventions that focus on reducing risk factors and enhancing protective factors. School-based curricula, certain structured afterschool activities, community- and home-based parent training programs, and community-wide prevention strategies have all been found to be effective in reducing adolescent drug use, delinquency, violence, and other problem behaviors (Hawkins & Catalano, 2004; Mihalic, Fagan, Irwin, Ballard, & Elliott, 2004; Sherman, Gottfredson, MacKenzie, Eck, Reuter, & Bushway, 1997; Welsh & Farrington, 2006). Despite their availability, such programs have not been widely disseminated in communities; many schools and service agencies use prevention approaches that have little or no evidence of effectiveness (Ennett, Ringwalt, Thorne, Rohrbach, Vincus, Simons-Rudolph, & Jones, 2003; Gottfredson & Gottfredson, 2002; Kumpfer & Alvarado, 2003; Wandersman & Florin, 2003). For example, Kumpfer and Alvarado (2003) estimated that only about 10% of practitioners implement family-focused programs that have evidence of effectiveness, and a national study of schools (Ringwalt, Ennett, Vincus, Thorne, Rohrbach, & Simons-Rudolph, 2002) found that 82% reported using drug prevention curricula, but only 27% were implementing programs that had evidence of success in reducing substance use. Even when organizations select a tested, effective prevention approach, they often do not implement it with fidelity and fail to adhere to the standards delineated by program designers (Gottfredson & Gottfredson, 2002; Hallfors & Godette, 2002; Kumpfer & Alvarado, 2003). Kumpfer and Alvarado (2003) reported that only about one-fourth of practitioners implement family-focused programs with integrity, and a national assessment of school-based prevention programming (Hallfors & Godette, 2002) found that only 19% of districts were implementing curricula with fidelity, while the other districts delivered programs with untrained teachers, without the required materials, or with misspecification of the population to be served (e.g., targeting high-risk students with universal programs). The development and testing of strategies for disseminating effective preventive interventions and improving the quality of community-based replications of these interventions are priorities for prevention research (Glasgow, Lichtenstein, & Marcus, 2003; Pentz et al., 2006; Saul, Duffy, Noonan, Lubell, Wandersman, Flaspohler, Stillman, Blachman, & Dunville, 2008; Spoth & Greenberg, 2005; Wandersman, 2003). Few models have been identified that are effective in facilitating translational research (Pentz et al., 2006; Rohrbach et al., 2006; Woolf, 2008) or in helping to bridge the gap between science and practice (Arthur & Blitz, 2000; Saul et al., 2008). More research is needed to investigate processes through which practitioners gain access to tested and effective interventions and put them into everyday use. Community coalitions have the potential for translating scientific principles into effective prevention action (Butterfoss, Goodman, & Wandersman, 1993; Specter, 2008; Wandersman, 2003; Wandersman & Florin, 2003). While some research has cautioned that community coalition initiatives are difficult to enact (Wandersman & Florin, 2003), and some studies have indicated that coalition efforts have not achieved significant improvements in healthy youth behavior (Collins, Johnson, & Becker, 2007; Flewelling, Austin, Hale, LaPlante, Liebig, Piasecki, & Uerz, 2005; Hallfors, Cho, Livert, & Kadushin, 2002), there is emerging evidence that coalitions can prevent the development of youth drug use and delinquency (Feinberg, Greenberg, Osgood, Sartorius, & Bontempo, 2007; Spoth, Redmond, Shin, Greenberg, Clair, & Feinberg, 2007). The PROSPER (Promoting School/community-university Partnerships to Enhance Resilience) model, for example, demonstrated improvements in youth outcomes using a collaborative approach that linked research scientists with community teams comprised of staff from local land-grant university extension offices, teachers or administrators from public schools, health and social service providers, parents, and youth (Spoth, Guyll, Lillehoj, Redmond, & Greenberg, 2007). A randomized, controlled evaluation of this model showed that the 14 PROSPER communities successfully implemented selected parent training and school-based drug prevention curricula (Spoth et al., 2007) and achieved greater reductions in student substance use initiation and past-year marijuana and inhalant use compared to the 14 control communities (Spoth et al., 2007). Evidence that coalitions can be effective and recognition that the widespread reduction of youth problem behaviors necessitates community-wide prevention efforts has increased calls for community-driven, collaborative approaches to prevention (Specter, 2008; Woolf, 2008). Yet, more information is needed to understand the extent to which communities can effectively form, maintain, and sustain coalitions, the challenges faced during coalition operations, and coalition-driven effects to select and successfully implement tested and effective prevention strategies. This paper describes these issues using data from a process evaluation of 12 communities utilizing the Communities That Care (CTC) prevention system (Hawkins & Catalano, 1992). Unlike the PROSPER model, which focuses on improving youth outcomes through land-grant university extension services, educational infrastructures and school-based preventive interventions (Spoth, Greenberg, Bierman, & Redmond, 2004), CTC relies on broad-based, diverse community coalitions to implement a range of prevention practices to address community-specific needs (Hawkins & Catalano, 1992; Hawkins, Catalano, & Arthur, 2002). It provides communities with an organizational structure and methodology for facilitating the transmission of prevention science concepts and practices to community action (Hawkins & Catalano, 1992). The utility of the CTC system in reducing youth problem behaviors is being investigated in a randomized, controlled evaluation of 24 communities in the Community Youth Development Study (Hawkins, Catalano, Arthur, Egan, Brown, Abbott, & Murray, 2008). Previous papers have described implementation of the CTC process in the 12 intervention communities during the first 2 to 3 years of this study, when coalitions were forming and new prevention strategies were being adopted and implemented (Fagan, Hanson, Hawkins, & Arthur, 2008; Quinby, Fagan, Hanson, Brooke-Weiss, Arthur, & Hawkins, 2008). This paper extends this research by evaluating communities’ fidelity to the CTC system and selected prevention programs over five years. Two research questions are addressed: (a) To what extent did communities faithfully replicate and maintain the core components of the CTC system? (b) To what extent were the specific prevention programs selected by communities implemented and maintained with fidelity? The answers to these questions provide information on the utility of relying on community-based coalitions to enact translational research. We describe implementation of the CTC system over five years in order to identify challenges associated with early coalition formation, organization, goal-setting, and planning, all of which can be difficult to achieve (Wandersman & Florin, 2003), and to investigate coalition maintenance over time. Long-term coalition sustainability has not been much studied, but there is recognition that maintenance is difficult because coalitions may face turnover in membership, shifts in goals and priorities, and waxing and waning of members’ time and support for prevention (Feinberg, Meyer Chilenski, Greenberg, Spoth, & Redmond, 2007; Leviton, Herrera, Pepper, Fishman, & Racine, 2006). We also describe the processes by which coalitions manage the delivery of specific prevention activities. Although a focus on implementing tested, effective programs has been linked to coalition effectiveness (Flewelling et al., 2005; Hallfors et al., 2002), there has been little research regarding how well coalitions oversee program replications. In addition, while attention to program implementation issues is increasing (Durlak & DuPre, 2008; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005), many evaluations have focused on barriers to program adoption or on challenges faced during early stages of implementation. Comparatively little is known regarding the maintenance and sustainability of preventive innovations (Saul et al., 2008), particularly programs overseen by local coalitions. A five-year analysis of implementation is important because it often takes several years before new preventive innovations are fully adopted and integrated into agencies and organizations, and studies that do not investigate implementation processes over several years may fail to accurately measure the true extent of fidelity (Fixsen et al., 2005).