This summary (written as a section in a Handbook) begins a discussion of how and why the implementation and institutionalization of school programs need to be based on evidence-based, well-planned and well-executived processes, strategies and procedures. Research, monitoring and other attention needs to examine this critical factor in the success or faliure of programs. (Use the "Thread" tool at the bottom of the page) and/or to suggest research, resources, experts, examples and other information related to this point (Use the Easy Edit at the top of the page to add suggestions directly on the page).

Evidence-based, Strategic, Practical Implementation and Sustainability

These are the key points from the ten broad implementation strategies suggested by the International School Health Network:

6. Identify the local mechanisms/drivers of change, implementation and sustainability and use evidence-based implementation strategies.

6.1 Identify key mechanisms and local drivers.

6.2 Use an evidence-based implementation process including a) planned, evidence-based diffusion/ implementation model b) required parent involvement c) required student engagement d) required community coordination e) required staff involvement f) required expert review g) required evaluation and reporting procedures.

There are a number of mechanisms that will support or hinder implementations such as staff competencies, access to skilled health promotion support, leadership and advocacy, establishing a practical context, nurturing a critical mass of people within the organization who ‘understand’ the principles of health promotion (‘multipliers’), providing access to a ‘tool’ or framework. There are mechanisms and processes that will affect the initiation, development, implementation and durability of programs. Each local situation will have key local drivers & barriers (key people, processes, issues, history, relationships etc). Strategic planning as well as operational plans need to be developed to use the opportunities or address the barriers.

Application to school substance abuse prevention
(Contributors are invited to add statements of good practice or to identify implications related to the point being made on this page.)

• Good/promising practice UNODC Principle 4. Collaborative partnerships should be developed for decision-making Students, school personnel, parents, prevention practitioners, referral agencies and the wider community should collaborate to make decisions on drug policy, including on the management of drug incidents. A collaborative approach to policy development reinforces desired values and consistent behaviours at school, in the home and among the community. (UN Office on Drugs & Crime)

• Good/promising practice Consider the local system, community, school and teacher factors that will affect the implementation of school substance abuse prevention programs (Canadian Assopciation for School Health, pp 50-53). See below for a more complete explanation.

Theory and models can be used to plan, evaluate and implement programs including diffusion of innovations, systems change, organizational development, community development and staff development theory Implement them effectively using a variety of planning and training tools. Identifying and engaging early adopters is one strategy for change. Adopter concerns should be addressed directly through concerns-based adoption planning models. The concept of critical mass for change may be particularly relevant to school health promotion, both in terms of introducing change but also in achieving enough of a dose for an appropriate duration sufficient for having an impact on health or learning. The characteristics of the innovation will affect adoption, implementation and institutionalization. Staff participation is also critical to success and effectiveness. Professional learning communities and communities of practice that encourage staff mentorship and collegial reflection on practice are being used more in the education and health sectors. Sound program evaluation methods should be used to evaluate results and evolve programs. Fidelity in implementation will compete with natural /inevitable tendencies to adapt innovations to local circumstances. This tension should be recognized from the outset in program planning.

Application to substance abuse prevention
(Contributors are invited to add statements of good practice or to identify implications related to the point being made on this page.)

• Good/promising practice UNODC Principle 9. Drug abuse prevention programmes and their outcomes should be evaluated regularly to provide evidence of their worth and to improve the design of future programmes. Some drug abuse prevention education programmes are not effective and some are counterproductive. Schools can avoid poor practices if they refer to principles, guidelines and models of good practice as standards to inform and guide the evaluation of programmes and outcomes. (UN Office on Drugs & Crime)

• Good/promising practice UNODC Records of drug incidents: these should be kept and due attention should be paid to the protection of the rights and privacy of all those involved. (UN Office on Drugs & Crime)

Local factors affecting implementation of SAP programs This page discusses how local and system wide factors can affect the implementation of school substance abuse prevention programs.

A major question that arises from the experimental or quasi-experimental research findings reported in this knowledge summary – much of it conducted in the U.S. and other countries – is, how hard is it to take those findings from controlled conditions and achieve the same results in programs in real-world settings in Canada? This is sometimes referred to as bridging research and practice, and it has generated considerable discussion and is increasingly the subject of study among researchers.

Given the sense of political and social urgency in the U.S., there has been a rush to disseminate programs that have been found to be effective in small, well-controlled efficacy trials, which has been criticized. Without replicating a program’s findings with different populations in less controlled settings, it is far from certain whether the program will in fact prove to be effective outside the controlled conditions of an experiment.[i] [ii]

There are a myriad of school drug prevention programs available that bill themselves as “evidence-based” according to the developing researchers or sponsors who understandably may be more enthusiastic about the program’s prospects than an objective observer. There are also a number of guides on evidence-based programs or principles that provide more objective advice, however these often reflect some bias as well.[iii] [iv] Consequently, school or public health personnel tasked with program selection or development need to be cautious and seek advice that is well-based.

If Canadian school personnel do not often refer to research articles or “best practice” guides when considering a new program (as their counterparts in the U.S. report)[v] it is important that they seek advice from credible (e.g. government- or university-linked) public health or addictions experts. To begin to understand the unresolved historical and contemporary issues facing Aboriginal peoples in Canada, school and public health personnel as well as researchers need to seek out information from elders or Aboriginal organizations.

Upon developing or selecting a program, a number of factors have been shown or suggested to influence whether implementation will be sustainable and of high quality. This section summarizes the research-based discussion on these factors for classroom-based models and whole school approaches.

Classroom-based drug education models

Delivering programs as designed, the extent to which teachers deliver evidence-based programs is low in the U.S. and believed to be low in this country. There are numerous factors that play into whether, and if so how, a teacher delivers a drug education program in a sustained high quality manner. These factors can be organized according to system-level and teacher-level factors.[vi]

System level factors

School readiness: there are a number of factors linked to whether a school is ready to take on a new drug education program in an effective and sustainable manner. Schools well positioned to take on a new program:

• have formally assessed the need for programming;[vii]
• have an open stance toward innovation and have built in processes for planning and preparing to implement new programs;[viii] [ix]
• have broad acceptance of the need and make the decision to take on a new program with teacher input rather than from the top-down.[x] It’s been suggested that a sense of personal commitment and ownership toward a new program/practice among teachers will result in stronger implementation than imposed requirements;[xi] [xii]
• have demands on teachers that are manageable(e.g. they are not overwhelmed by increasing class sizes or by preparing students for high-stakes standardized testing);[xiii]
• have determined how they can accommodate the program in a crowded curriculum;[xiv]
• consider a phased in approach:

o Pre-implementation phase: this is the time to consider personnel capacities, materials required, total costs, space needs, school goals, the goodness of fit of a program, and time requirements for implementation. These types of issues become barriers to adoption and to permanence if not adequately addressed in the early stages. Upon addressing these issues, implementation plans are developed;[xv]
o Supported implementation phase: time during which teachers are trained in the program and receive ongoing in-classroom consultation on program; and;
o Sustainability Phase, when external support for implementation (i.e., training, consultation) has been withdrawn;[xvi]

• have confirmed the resources necessary to implement and sustain over the longer term (e.g. funding for training, to pay substitutes, etc.);[xvii]
• incorporate the program and program supports into the core business of the school; that is they institutionalize the program.[xviii] [xix] [xx]

Swisher (2006) identifies the following as features of institutionalization:[xxi]

• being a line item in the permanent agency budget;
• having a place in the agency’s organization chart;
• having personnel or full time equivalents (FTEs) assigned to specific prevention tasks;
• having position descriptions that include prevention functions and level of effort; · having facilities and equipment for program operations;
• developing an institutional memory for important agreements and understandings.

Leadership: leadership at the board and school level is critical to ensuring initial readiness and longer term implementation. Principals serve as “gatekeepers” for new programs that are introduced and implemented in their schools, so, their attitudes and behaviour can significantly affect teachers’ implementation of new programs.[xxii] Knowledgeable and supportive school leadership can be instrumental in establishing school readiness as above (e.g. time, resources, incentives, and training allocated for the program as well as the expectation of accountability).[xxiii]

Informal leaders, opinion leaders and champions in the community can be helpful in securing funds and overcoming barriers.[xxiv] Initial hands-on engagement by leaders needs to be continued to some degree. The pattern of handing off responsibility of the program following introduction often results in diminishing implementation over time.[xxv]

Sobeck and colleagues (2006) found that those to whom lead responsibilities are passed tend to have little authority to make decisions around resources or to deal with non-compliance. Nonetheless, an ongoing coordination position at the school or board level can be very helpful. A broad United Kingdom initiative to test widespread implementation of a drug education program (Blueprint, 2006) found a School Drug Advisor role to be vital for supporting ongoing implementation.[xxvi] Advisors’ tasks included: ·

• supporting classroom delivery, e.g. by working alongside school staff, teaching and advising on effective delivery of the lessons; · acting as a link point for partnerships to support schools;
• acting as a local media contact;
• managing and co-ordinating a series of alliances in drug education designed to promote effective practice across schools with external contributors of drug education; and
• managing a review of school drug policy.

Stakeholder support: Given the sensitivity around substance use issues, parents and other members of the community can undermine a prevention program if they do not accept or understand it.[xxvii] It is important to note that there may be two stakeholder perspectives in a community; one being an exaggerated anti-drug stance and the other a more realistic perspective about what schools can reasonably achieve. Hawthorne (2001) notes a paradox in that the former group can be instrumental in giving visibility to the issue but their rhetoric may lead to program criteria and expectations that are not realistic.[xxviii] The need to harmonize stakeholder support is particularly important in considering drug education programs that aim to prevent or reduce hazardous use patterns and harms, particularly in relation to illegal drugs.

Murmane and colleagues (2002) in Australia note that the harm reduction and illegality issues create enormous dilemmas for schools, as they don’t wish to be perceived as “normalising” or being “soft on drugs”. When they consulted with school personnel they found that principals were concerned that drug education programming may lead to the school being seen as a “drug school” which will impact negatively on the school’s profile. Their work and the work by Poulin and Nicholson (2005) in Nova Scotia show that considerable confusion and concern exists among stakeholders around “harm reduction” programming in schools.[xxix] Parent and community education and an open collaborative approach to arriving at clear program aims and elements are needed to reduce fears and misgivings.[xxx]

Classroom level factors

Han and Weiss (2005) identified several classroom level factors that influence the quality and sustainability of classroom programs, including: (a) teachers’ beliefs about their own abilities; (b) professional burnout, and; (c) their beliefs about the acceptability of the program.[xxxi]

Teacher self-efficacy: teachers’ sense of their own abilities has been found to relate to educational outcomes such as instructional behaviour, persistence in a teaching situation, enthusiasm, and commitment to teaching, as well as student outcomes such as achievement, motivation, and students’ own sense of efficacy. Moreover, teachers with a strong sense of efficacy appear more open to new ideas and more willing to experiment with new methods to better meet their students’ needs.[xxxii] This is noteworthy because there is evidence that teachers do not have a sense of efficacy with interactive methods or with this subject area.[xxxiii] [xxxiv]

Teacher burnout: Han and Weiss suggest three aspects of burnout with implications for teachers taking on new drug education programming: (a) emotional fatigue: a teacher that is tired and emotionally drained is not so likely to take up new additional programming. (b) depersonalization: educator no longer has positive feelings about students and display indifferent or even negative attitudes toward students. (c) a sense of low personal accomplishment from the job: teacher feels he/she no longer is contributing to students’ development.

Teachers’ perception of program acceptability: the issues mentioned above in relation to stakeholder support are particularly relevant to teachers. Drawing from Han and Weiss, several factors would likely affect teachers’ judgments of a drug education program’s acceptability, including: (a) their sense of the severity of their students’ drug issues; (b) the acceptability of the aims and messages of the drug education program (as discussed above with stakeholders; (c) the effectiveness of the program[xxxv] and; (d) the complexity and amount of time required to implement the program.[xxxvi] For example, Poulin and Nicholson found that harm reduction programming was viewed as unacceptable by teachers at the junior high school level in Nova Scotia in 1999.[xxxvii]

Teacher professional development: given teachers’ lack of comfort with the topic area and the fact that interactive methods, though critical to program success, tend not to be employed by teachers, professional development would seem to offer at least a partial solution. However, research doesn’t provide strong direction. What appears clear is that training increases the likelihood that a teacher will actually implement a program,[xxxviii] [xxxix] [xl] nevertheless implementation still declines over time (e.g. within the second year).[xli]

Studies that compare live training workshops to video and self-instruction approaches sometimes but not always show the live sessions to result in higher implementation fidelity.[xlii] [xliii] [xliv] Researchers have begun to explore the effectiveness of using new technologies to train teachers, such as online training and interactive training sessions via satellite television but no clear indication of effectiveness is available.[xlv] Though research evidence is lacking at this point, there is a consensus that (whatever the mode) training needs to allow direct opportunities to observe, model, practice and receive feedback on interaction-based instructional skills in order to increase teachers’ sense of competence with these methods.[xlvi] [xlvii]

Training may simply not be sufficient by itself to maintain quality implementation by teachers over the long term.[xlviii] In-class performance feedback has been shown to lead to enduring change in teacher performance.[xlix] When strong delivery of an effective program does occur, Han and Weiss suggest it will fuel a positive feedback loop, in that the teacher will experience success and be motivated to continue to correctly implement the program.[l] Instructional skills training and opportunity for performance feedback are important when introducing a new drug education program but it is apparent that they are not sufficient to ensure ongoing quality implementation of the program.

A broad workforce development approach, as is recommended in other areas of practice, is necessary.[li] [lii] This approach would accept that advancing drug education practice requires long-term thinking and recognition of the importance of the organizational context within which programs are being implemented. A workforce development approach would also give attention to pre-service training for education students to improve their understanding and implementation of prevention methodologies. Swisher (2006) noted that most colleges of education in the U.S. are not providing this type of professional development;[liii] the situation in Canada is unknown but doesn’t likely differ.