• staff competencies,
  
• access to skilled health promotion support,
  
• leadership and advocacy,
  
• establishing a practical context
• having a champion, few key people to lead, and succession plan to identify new people to eventually replace these champions
  
• nurturing a critical mass of people within the organization who ‘understand’ the principles of health promotion (‘multipliers’),
  
• providing access to a ‘tool’ or framework.

Each local situation will also have key local drivers & barriers that need to be addressed but are often ignored in research articles or planning manuals because they are different and specific to each situation and the individuals involved. These need to be addressed through strategic planning. They include

• key people acting as decision-makers, gatekeepers, influencers and others
• critical processes such as annual priority setting, budget-making,
• local issues that relate to the program
• recent and significant incidents (such as a death or crisis) that have galvanized public, political and professional attention.
  
• the history of the issue, organization and community context as they relate to the program
• relationships between the various partners, allies and competitors to the program

Consistent and Similar Advice from Several Sources

There is a growing body of evidence-based and experience-tested knowledge about implementation that this summary will draw from in its next version. These sources are briefly summarized below.

The Canadian Association for School Health (2006) has described several factors that influence the implementation process.

(Excerpt from "School-based and school-linked prevention of substance use problems: A knowledge summary", Canadian Association for School Health, 2008.

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 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 U.S. counterparts report) [v] it is important that they seek advice from credible (e.g. government- or university-linked) public health or addictions experts.

Also, 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
As was discussed in Section V. A., 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:
• 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]
• Supported implementation phase: time during which teachers are trained in the program and receive ongoing in-classroom consultation on program; and;
• 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][xxiii][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][xxvi] Advisors’ tasks included: 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). Informal leaders, opinion leaders and champions in the community can be helpful in securing funds and overcoming barriers. 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.

• 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.

Best advice 18 : employ a broad workforce development approach that accounts for the various factors affecting practice; the amount and quality of pre-service and in-service teacher education are very important but other factors are also at play.

Qualities of the program : although there is no evidence to date, it is quite possible that programs that are complex, that require significant preparation time, or have unclear guides, are less likely to be delivered as intended.[liv] [lv] This is also likely of programs requiring significant delivery time. It is clear that teachers have great difficulty finding enough time in their schedules to deliver extensive substance education programs along with the various other health and social development programs they may be called upon to deliver (e.g. HIV/AIDS, careers, character, civics, conflict resolution, delinquency, dropout, family life, health, morals, multiculturalism, pregnancy, service learning, truancy, and violence).

The effect of this type of “issue de jour” approach has been criticized as having a fragmenting and disruptive effect on school efforts to address problems. [lvi] Greenberg and colleagues argue for programming that not only better coordinates the issue areas but also ties them more closely to the academic aims of schools. They call for what they refer to as Social, Emotional and Academic Learning (SEAL) that recognizes and distills the common elements of the many health and social programs – but which importantly, also promote academic success. “SEAL” programming recognizes that many health, social and academic problems share common factors (self-knowledge, assertiveness, resolving conflicts, etc) that can be taught like academic skills in that learning is incremental, addressing increasingly complex situations students face with academics, social relationships, citizenship, and health.

Proponents argue that there is a strong theoretic rationale for students’ social/emotional competence contributing to improved academic performance in several ways (e.g. students who become more self-aware and confident about their learning abilities try harder, and students who motivate themselves, set goals, manage their stress, and organize their approach to work perform better). Programs advocated by these researchers (see http://www.casel.org/) may be curriculum-based, but they often have multiple components including family programming and attention to school environment. The ability of these programs to improve a range of academic, health and social outcomes has some research support (the Seattle Social Development project, Section V. D. an example) and the rationale is persuasive. [lvii]

Another way of tying together academic and health and social aims is to integrate health/social topics into other subject areas. This has been proposed over the years and teachers no doubt find ways of accomplishing this through their own means but there has been little research attention to this approach. Swisher (2000) notes that U.S. National Institute on Drug Abuse (NIDA) researchers were working with teachers to develop lessons that combine a basic instructional objective and a prevention objective simultaneously and suggests this kind of integration of the subject matter could help sustain prevention objectives over the longer term. [lviii]

Coordination of whole school, comprehensive approaches By their nature, whole school approaches require still more attention to school readiness issues as discussed above. Because these initiatives usually call for attention to the school environment, and closer ties with parents, often accompanied by new curricular programming, preparation is critical. Researchers associated with Australia’s Gatehouse project conclude that a great challenge for these approaches involving systemic changes is that they take a great deal of time and resources.[lix]

It is possible that the breadth of the changes called for with this type of approach may lead schools to shy away from them. If this approach is presented to schools as another project to add on, they may indeed be very hesitant. The demands on schools to promote academic success and also implement various social and health programs advocated by community interests understandably make schools wary of another “add on” program. Schools are typically so preoccupied with ongoing instructional and management reforms that social and health programs are often seen as beyond the schools core business and dealt with “off the corner of the desk”. [lx] [lxi]

Consequently, researchers increasingly claim that the long term success of comprehensive health and social programs lies in their ability to anchor them in the core mission of schools. [lxii] [lxiii] [lxiv] That is, they must fully accept that schools are first and foremost accountable for educating young people, and that they tend to become concerned with a problem when it is clearly a barrier to student learning. But the majority of students who end up having academic difficulties often experience a range of social/health barriers (e.g., violence, substance use issues, frequent school changes, and the numerous problems confronting recent immigrants and families living in poverty).

So, a strong case can be made that these various social and health issues also represent barriers to learning, and call for schools, families, and communities to work together to address both through a comprehensive approach. [lxv][lxvi] Gatehouse researchers found that many of the schools they worked with initially saw the project as a “welfare and student support” project. But through the process of implementation they found that a focus on student engagement and connectedness to school was a sound way to promote both emotional well-being and learning outcomes.

Adleman and Taylor point out that comprehensive approaches that are intended to support health and learning aims can paradoxically bring a new form of fragmentation. In many cases fragmentation arises because these initiatives focus mostly on linking community services to schools (e.g. substance abuse counselling) with too little thought given to connecting community programs with existing programs operated by the school. So, parallel (rather than integrated) programming can arise and personnel co-located at schools can find themselves operating in relative isolation of existing school programs and services. They point out that as a consequence a student identified as at risk for substance abuse, dropout, and suicide may be involved in three counselling programs operating independently of each other. Consequently various researchers have called for parties to move beyond program cooperation, and strive for program integration—with health/social advocates and educators working together to identify shared values, goals, and strategies.[lxvii] [lxviii]

A long-term view is required when implementing comprehensive programs and policies. It is important to understand that these initiatives will not likely lead to immediate change at the individual level. So some researchers argue that other interim markers of success associated with process need to be identified earlier (e.g. level of student-teacher trust) to guide schools. [lxix] Others suggest these initiatives be rolled out in sequence to minimize the strain on resources and to maintain interest. This was the approach taken by the government of the United Kingdom in its strategy to implement comprehensive school programming across that country in support of its national drug strategy.[lxx]

To facilitate roll-out and effective relations between programs it may be helpful to consider a “stepped-care approach” as advocated by Abrams and Clayton (2001, p. 324). [lxxi] A guiding principle of this model is the use of the least intensive (and expensive) level first and “stepping up” a “client” when a less intensive intervention has not been effective. Three steps are often proposed and in the school setting could take the following form:
Step 1: universal classroom and school-wide programming
Step 2: screening for higher-risk students who receive targeted brief motivational interventions
Step 3: more intensive clinical interventions for the smaller but important subgroup with severe problems

Comprehensive approaches often involve parents and this summary has found that the evidence for universal as well as targeted school-family programming is good. However, there are significant challenges to involving families in school programming. Programs seeking to involve parents often have problems reaching them. Participation rates tend to be very low and programs often fail to attract parents whose offspring are at the highest risk of substance use or other problems.[lxxii]

Stormshak (2005) reports on one approach at the middle school level, the Family Resource Centre (FRC), which allows for more focused attention to parent engagement. These centres, staffed by half-time professionals, deliver specific family programming and more generally support school personnel in their efforts to communicate and work with families. The study design was not controlled but the authors reported that FRC services significantly reduced the growth in problem behaviour over the three years of study. [lxxiii] Teacher training is an important consideration in the implementation of comprehensive programming.

As has been reported earlier in this summary, the Gatehouse project included 40 hours of teacher training that was evenly divided between the curriculum and the environmental elements of the project. Another Australian study tested teacher training in the management of school substance use issues, and found that participating teachers demonstrated more favourable attitudes and practices in regard to integrated, supportive management of these issues in comparison to non-participating teachers; however they found little change in school practices. [lxxiv]

So, as is the case with classroom practices, it appears that training for policy or environmental change has some value, but needs to be a part of a broader, workforce development approach that accounts for the various factors involved with changes in school practices. This approach would also involve reviewing university teacher and school psychologist education to determine how best they can be prepared to contribute to comprehensive school approaches. [lxxv]

Any such effort needs to view teachers in a broad ecological perspective and examine ways that their training, development, and work as professionals can engage them to take part in efforts that attempt to create optimal environments for them and their students. [lxxvi] At the same time, social scientists and school health advocates need to receive more training to help them understand how to enter and work with school systems. Such training could help these professionals learn how best to develop joint agendas with schools to improve the range of student outcomes discussed in this knowledge summary.[lxxvii]

Best advice 19 : pre-service and in-service training of teachers, counsellors, and school psychologists, as well as partners (i.e. police and addiction and mental health professionals) need to include how each can contribute to the whole school environment and comprehensive approaches.

Best advice 20: those wishing to partner with schools to promote learning and prevent substance abuse and other health and social problems need to increase their understanding of how to effectively seek entry and work with school systems.

[i] August, G.J., Winters, K.C., Realmuto, G.M., Tarter, R., Perry, C., & Hektner, J.M. (2004). Moving evidence-based drug abuse prevention programs from basic science to practice: Bridging the efficacy-effectiveness interface. Substance Use & Misuse, 39(10-12), 2017-2053.
[ii] Adelman, H.S., & Taylor, L. (2003). Creating school and community partnerships for substance abuse prevention programs. The Journal of Primary Prevention, 23(3).
[iii] Brounstein, P.J., Gardner, S.E., & Backer, T.E. (2006). Research to practice: Efforts to bring effective prevention to every community. The Journal of Primary Prevention, 27(1).
[iv] Petrosino, A. (2003). Standards for Evidence and Evidence for Standards: The Case of School-Based Drug Prevention. The Annals of the American Academy of Political and Social Science, 587(1), 180-207.
[v] Rohrbach, L.A., Ringwalt, C.L., Ennett, S.T., & Vincus, A.A. (2005). Factors associated with adoption of evidence-based substance use prevention curricula in US school districts. Health Education Research, 20(5), 514-526.
[vi] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[vii] Sobeck, J.L., Abbey, A., & Agius, E. (2006). Lessons learned from implementing school-based substance abuse prevention curriculums. Children and Schools, 28(2), 77-85.
[viii] Johnson, K., Hays, C., Daley, C., & Hayden Center. (2004). Building capacity and sustainable prevention innovations: A sustainability planning model. Evaluation and Program Planning, 27, 135-149.
[ix] Berryhill, J.C., & Prinz, R.J. (2003). Environmental interventions to enhance student adjustment: Implications for prevention. Prevention Science, 4(2).
[x] Pentz, M.A., Jasuja, G.K., Rohrbach, L.A., Sussman, S., & Bardo, M.T. (2006). Translation in tobacco and drug abuse prevention research. Evaluation & the Health Professions, 29(2), 246-271.
[xi] Johnson, K., Hays, C., Daley, C., & Hayden Center. (2004). Building capacity and sustainable prevention innovations: A sustainability planning model. Evaluation and Program Planning, 27, 135-149.
[xii] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[xiii] Sobeck, J.L., Abbey, A., & Agius, E. (2006). Lessons learned from implementing school-based substance abuse prevention curriculums. Children and Schools, 28(2), 77-85.
[xiv] Murnane, A., Snow, P., Farringdon, F., Munro, G., Midford, R., & Rowland, B. (2002). National school drug education strategy. Effective implementation practice in relation to school drug education. Perth, Australia: National Drug Research Institute, Curtin University.
[xv] Swisher, J.D. (2000). Sustainability of prevention. Addictive Behaviors, 25, 965-973.
[xvi] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[xvii] Swisher, J.D. (2000). Sustainability of prevention. Addictive Behaviors, 25, 965-973.
[xviii] Payne, A.A., Gottfredson, D.C., & Gottfredson, G.D. (2006). School predictors of the intensity of implementation of school-based prevention programs: Results from a national study. Prevention Science, 7(2), 225-237.
[xix] Johnson, K., Hays, C., Center, H., & Daley, C. (2004). Building capacity and sustainable prevention innovations: A sustainability planning model. Evaluation and Program Planning, 27, 135-149.
[xx] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[xxi] Swisher, J.D. (2000). Sustainability of prevention. Addictive Behaviors, 25, 965-973.
[xxii] Ringwalt, C.L., Ennett, S., Johnson, R., Rohrbach, L.A., Simons-Rudolph, A., Vincus, A., & Thorne, J. (2003). Factors associated with fidelity to substance use prevention. Curriculum guides in the nation’s middle schools. Health Education & Behavior, 30(3), 375-391.
[xxiii] Johnson, K., Hays, C., Center, H., & Daley, C. (2004). Building capacity and sustainable prevention innovations: A sustainability planning model. Evaluation and Program Planning, 27, 135-149.
[xxiv] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[xxv] Sobeck, J.L., Abbey, A., & Agius, E. (2006). Lessons learned from implementing school-based substance abuse prevention curriculums. Children and Schools, 28(2), 77-85.
[xxvi] Baker, P.J. (2006). Developing a blueprint for evidence-based drug prevention in England. Drugs: Education, Prevention and Policy, 13(1), 17-32.
[xxvii] Sobeck, J.L., Abbey, A., & Agius, E. (2006). Lessons learned from implementing school-based substance abuse prevention curriculums. Children and Schools, 28(2), 77-85.
[xxviii] Hawthorne, G. (2001). Drug education: Myth and reality. Drug and Alcohol Review, 20(1), 111-119.
[xxix] Poulin, C., & Nicholson, J. (2005). Should harm minimization as an approach to adolescent substance use be embraced by junior and senior high schools? Empirical evidence from an integrated school and community-based demonstration intervention addressing drug use among adolescents. International Journal of Drug Policy, 16,
[xxx] Murnane, A., Snow, P., Farringdon, F., Munro, G., Midford, R., & Rowland, B. (2002). National school drug education strategy. Effective implementation practice in relation to school drug education. Perth, Australia: National Drug Research Institute, Curtin University.
[xxxi] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[xxxii] ibid
[xxxiii] Ennett, S.T., Ringwalt, C. L., Thorne, J., Rohrbach, L.A., Vincus, A., Simons-Rudolph, A., & Jones, S. (2003). A comparison of current practice in school-based substance use prevention programs with meta-analysis findings. Prevention Science, 4(1), 1-14.
[xxxiv] Murnane, A., Snow, P., Farringdon, F., Munro, G., Midford, R., & Rowland, B. (2002). National school drug education strategy. Effective implementation practice in relation to school drug education. Perth, Australia: National Drug Research Institute, Curtin University.
[xxxv] Ringwalt, C.L., Ennett, S., Johnson, R., Rohrbach, L.A., Simons-Rudolph, A., Vincus, A., & Thorne, J. (2003). Factors associated with fidelity to substance use prevention. Curriculum guides in the nation’s middle schools. Health Education & Behavior, 30(3), 375-391.
[xxxvi] Bishop, D., Bryant, K.S., Giles, S.M., Hansen, W.B., & Dusenbury, L. (2006). Simplifying the delivery of a prevention program with web-based enhancements. Journal of Primary Prevention, 27(4), 433-444.
[xxxvii] Poulin, C., & Nicholson, J. (2005). Should harm minimization as an approach to adolescent substance use be embraced by junior and senior high schools? Empirical evidence from an integrated school and community-based demonstration intervention addressing drug use among adolescents. International Journal of Drug Policy, 16, 403–414.
[xxxviii] Pentz, M.A., Jasuja, G.K., Rohrbach, L.A., Sussman, S., & Bardo, M.T. (2006). Translation in tobacco and drug abuse prevention research. Evaluation & the Health Professions, 29(2), 246-271.
[xxxix] Ringwalt, C.L., Ennett, S., Johnson, R., Rohrbach, L.A., Simons-Rudolph, A., Vincus, A., & Thorne, J. (2003). Factors associated with fidelity to substance use prevention. Curriculum guides in the nation’s middle schools. Health Education & Behavior, 30(3), 375-391.
[xl] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[xli] ibid
[xlii] Pentz, M.A., Jasuja, G.K., Rohrbach, L.A., Sussman, S., & Bardo, M.T. (2006). Translation in tobacco and drug abuse prevention research. Evaluation & the Health Professions, 29(2), 246-271.
[xliii] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[xliv] Baker, P.J. (2006). Developing a blueprint for evidence-based drug prevention in England. Drugs: Education, Prevention and Policy, 13(1), 17-32.
[xlv] Pentz, M.A., Jasuja, G.K., Rohrbach, L.A., Sussman, S., & Bardo, M.T. (2006). Translation in tobacco and drug abuse prevention research. Evaluation & the Health Professions, 29(2), 246-271.
[xlvi] ibid
[xlvii] Han, S., & Weiss, B. (2005). Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology, 33(6), 665-679.
[xlviii] ibid
[xlix] ibid
[l] ibid
[li] Pentz, M.A., Jasuja, G.K., Rohrbach, L.A., Sussman, S., & Bardo, M.T. (2006). Translation in tobacco and drug abuse prevention research. Evaluation & the Health Professions, 29(2), 246-271.
[lii] Roche, A.M. (2002). Workforce development issues in the AOD field: A briefing paper for the inter-governmental committee on drugs. Retrieved September 30, 2007, from http://www.nceta.flinders.edu.au/pdf/issues.pdf
[liii] Swisher, J.D. (2000). Sustainability of prevention. Addictive Behaviors, 25, 965-973.
[liv] Ringwalt, C.L., Ennett, S., Johnson, R., Rohrbach, L.A., Simons-Rudolph, A., Vincus, A., & Thorne, J. (2003). Factors associated with fidelity to substance use prevention. Curriculum guides in the nation’s middle schools. Health Education & Behavior, 30(3), 375-391.
[lv] Toumbourou, J.W., Rowland, B., Jefferies, A., Butler, H., & Bond, L. (2004). Preventing drug-related harm through school re-organisation and behavior management [Prevention research evaluation report No. 12]. Melbourne, Australia: Australia Drug Foundation. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/downloads/Prevention_Research_Quarterly/PRQ_04Nov_Early_intervention_in_schools.pdf
[lvi] Greenberg, M.T., Weissberg, R.P., O’Brien, M.U., Zins, J.E., Fredricks, L., Resnik, H., et al. (2003). Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. American Psychologist, 58, 466–474.
[lvii] ibid
[lviii] Swisher, J.D. (2000). Sustainability of prevention. Addictive Behaviors, 25, 965-973.
[lix] Bond, L., Glover, S., Godfrey, C., Butler, H., & Patton, G.C. (2001). Building capacity for system-level change in schools: Lessons from the gatehouse project. Health Education and Behavior, 28(3), 368-383.
[lx] Toumbourou, J.W., Rowland, B., Jefferies, A., Butler, H., & Bond, L. (2004). Preventing drug-related harm through school re-organisation and behavior management [Prevention research evaluation report No. 12]. Melbourne, Australia: Australia Drug Foundation. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/downloads/Prevention_Research_Quarterly/PRQ_04Nov_Early_intervention_in_schools.pdf
[lxi] Stormshak, E.A., Dishion, T.J., Light, J., & Yasui, M. (2005). Implementing family-centered interventions within the public middle school: Linking service delivery to change in student problem behavior. Journal of Abnormal Child Psychology, 33(6), 723-733.
[lxii] Adelman, H.S., & Taylor, L. (2003). Creating school and community partnerships for substance abuse prevention programs. The Journal of Primary Prevention, 23(3).
[lxiii] Stormshak, E.A., Dishion, T.J., Light, J., & Yasui, M. (2005). Implementing family-centered interventions within the public middle school: Linking service delivery to change in student problem behavior. Journal of Abnormal Child Psychology, 33(6), 723-733.
[lxiv] Toumbourou, J.W., Rowland, B., Jefferies, A., Butler, H., & Bond, L. (2004). Preventing drug-related harm through school re-organisation and behavior management [Prevention research evaluation report No. 12]. Melbourne, Australia: Australia Drug Foundation. Retrieved September 30, 2007, from http://www.druginfo.adf.org.au/downloads/Prevention_Research_Quarterly/PRQ_04Nov_Early_intervention_in_schools.pdf
[lxv] Adelman, H.S., & Taylor, L. (2003). Creating school and community partnerships for substance abuse prevention programs. The Journal of Primary Prevention, 23(3).
[lxvi] Bond, L., Glover, S., Godfrey, C., Butler, H., & Patton, G.C. (2001). Building capacity for system-level change in schools: Lessons from the gatehouse project. Health Education and Behavior, 28(3), 368-383.
[lxvii] Adelman, H.S., & Taylor, L. (2003). Creating school and community partnerships for substance abuse prevention programs. The Journal of Primary Prevention, 23(3).
[lxviii] Stormshak, E.A., Dishion, T.J., Light, J., & Yasui, M. (2005). Implementing family-centered interventions within the public middle school: Linking service delivery to change in student problem behavior. Journal of Abnormal Child Psychology, 33(6), 723-733.
[lxix] Inchley, J., Muldoon, J., & Currie, C. (2007). Becoming a health promoting school: Evaluating the process of effective implementation in Scotland. Health Promotion International, 22(1), 65-71.
[lxx] Baker, P.J. (2006). Developing a Blueprint for evidence-based drug prevention in England. Drugs: Education, Prevention and Policy, 13(1), 17–32.
[lxxi] Abrams, D. B., & Clayton, R. R. (2001). Transdisciplinary research to improve brief interventions for addictive behaviors. In P. M. Monti, S. M. Colby & T. A. O'Leary (Eds.), Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions. Retrieved September 30, 2007, from http://ajp.psychiatryonline.org/cgi/reprint/159/11/1958
[lxxii] Stormshak, E.A., Dishion, T.J., Light, J., & Yasui, M. (2005). Implementing family-centered interventions within the public middle school: Linking service delivery to change in student problem behavior. Journal of Abnormal Child Psychology, 33(6), 723-733.
[lxxiii] ibid
[lxxiv] Midford, R., Wilkes, D., & Young, D. (2005). Evaluation of the in touch training program for the management of alcohol and other drug use issues in schools. Journal of Drug Education, 35(1), 1-14.
[lxxv] Greenberg, M.T., Weissberg, R.P., O’Brien, M.U., Zins, J.E., Fredricks, L., Resnik, H., et al. (2003). Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. American Psychologist, 58, 466–474.
[lxxvi] Berryhill, J.C., & Prinz, R.J. (2003). Environmental interventions to enhance student adjustment: Implications for prevention. Prevention Science, 4(2), 65-87.
[lxxvii] ibid

The Best Practices Portal of the Public Health Agency of Canada has these tips for practical and strategic implementation of programs:

6.1 Engage partners early on to establish shared values and alignment of purpose.
This step is best done meeting face to face, where partners can speak to values and purpose, using stories and narrative, as well as making reference to more formal documents. It is important to identify common core values early on, as this is the foundation upon which the collaboration is based.

6.2 Establish concrete objectives and focus on visible results
Many group methods, preferably face to face, can be used to generate objectives. Focus first on identifying objects of change, including populations, organizations and policies. Once that is done, identify the most important changes to be made. Finally, establish targets for the change, including the amount of change and milestone dates. It is best to have a small number of people write the actual objectives, while using the large group of partners to identify possibilities and help in appraising the final product.

6.3 Identify and support a champion
Frank and open discussion, in which promising choices are considered against the chosen criteria, is the best way to select a champion, be it individuals or a group.The champion can be supported by providing them with background information highlighting important message concepts, key facts and statistics, stories, and compelling ways to make the points), and by assisting them in preparations for key communications, as well as evaluations and de-briefings.

6.4 Invest in the alliance building process
A sound partnership clearly outlines mutual expectations and obligations in the areas of personnel and money. Partners may have other costs, such as foregoing other opportunities and exposing themselves to potential risks.

6.5 Generate political support
Working with decision-makers and those that influence them can help generate support for your issue. Where appropriate, public support can be built through paid and earned media; one way to do this is by staging events. A variety of communication methods is ideal, beginning with relatively low profile correspondence and developing into meetings. Medium and high profile tactics to gain support may also be needed over time.

6.6 Share leadership, accountability and rewards among partners
Planning for the alliance must include carefully outlining responsibilities in terms of roles. Roles can vary and may relate to things both inside and outside of the operation of the alliance. For instance, leadership of the alliance can be shared through distributed roles or by changing roles (e.g. a rotating chairpersonship). There are many tools for assigning roles and identifying who is responsible, who is accountable, who is supporting, who is approving, and who is being informed as work proceeds. Mechanisms for monitoring progress and accountability are essential, as are plans for sharing anticipated gains.

Strategic planning as well as operational plans need to be developed to use the opportunities or address the barriers. The Canadian Association for School Health has identified these questions as a way of considering some important strategic issues:

1. What is the window of opportunity that will help you get started? (News story, incident, formal report, new boss, new funding, survey results, etc.)
2. Who are my potential partners? What is the hook for each of them? What would their roles be? Who are the competitors? How can they be avoided or turned around?
3. Think about the your CSH idea....who else owns it or thinks they own it? who is doing something or has done something similar? Are their ideas/concepts similar but expressed in different terminology or jargon? Make sure that you use different terms/words when you approach people who use those different terms/words/concepts.
4. What is your focus (is what “problem are you trying to fix)? Is the focus small enough to get started with something practical but big enough to be able to “grow” into a CSH approach?
5. What are the strengths of your school/organization/community? How can they be applied to this issue?
6. What are the weaknesses of your school/organization/community? How can they be overcome or at least alleviated for this issue?
7. Who will be your champions? How much time can you give? Who will be your immediate partners who can contribute a similar amount of time and effort?

The Canadian Association for School Health has also identified some important operational questions that also need to be considered as part of regular, operational planning:

1. Review what you, your school, local agencies and the local community are already doing on the issue.List the activities, people, resources, recent surveys, studies, facilities etc. Make notes where there may be potential connections and cooperation.
2. Connect to what is already happening in your school and community.Bring the people who are currently operating programs, services and activities that relate to your school health program. A “bring and brag” session is great for getting started.
3. Identify shared values or a common vision. Prepare a short statement that everyone can agree to and then take back to their respective organizations for approval. Try to include the issues, concerns, language and terms from as many people as possible in that statement.
4. Identify an activity for immediate success. Identify longer-term activities and actions.Try to have a couple of practical suggestions on-hand that can be done in a few months without new resources. Implement those activities right away, enabling people to work together and achieve success. Also identify some longer-term projects and activities that involve shared resources or applying for additional resources or advocating for better policies or programs.
5. Pick a priority area for action. Take a health issue that is of immediate concern to several organizations. Ensure that you have local evidence that the problem exists in your community. Select some achievable objectives for addressing that issue. Publicize your efforts and your success.
6. Build your CSH Infrastructure. Consider how you will use the activities and your focus issue to help your school or community become more comprehensive and cooperative in its approach to promoting health through schools and communities working together. (e.g. Link up isolated groups, create a school health council, help single issue groups to think and act more globally etc.)
7. Keep records and evaluate your efforts.Set up a system to document your efforts, pre and post activity needs and resources. Don’t try to attribute long-term behavioural change to small-scale activities. Be realistic about what you can achieve. But show the connection to health improvement by noting that your small change will have an impact on at least one determinant of health.

The Pan-American Health Organization has defined these factors as being critical to implementation:


Adapted from Vince Whitman, C., “Implementing Research-based Health Promotion Programmes in Schools: Strategies for Capacity Building,” Chapter 6 in S. Clift, B.B. Jensen (eds.) The Health Promoting School: International Advances in Theory, Evaluation and Practice. Copenhagen: Danish University of Education Press, 2005

Critical Mass and Supportive Norms

International & National Guidelines

Dedicated Time & Resources

Stakeholder Ownership & Participation

Team Training & Ongoing Coaching/Learning Community

Cross Sector Collaboration

Champions & Leaders at All Levels

Data-Driven Planning & Decision Making

Adapting to Local Concerns

Attention to External Forces

Produce Changes in Policy & Practice

Administrative & Management Support

Stage of Readiness

Vision & Concept


List of Promising, good or better practices at:

All Levels

• Engage partners early on to establish shared values and alignment of purpose (Public Health Agency of Canada)
• Establish concrete objectives and focus on visible results (Public Health Agency of Canada)
• Identify and support a champion (Public Health Agency of Canada)
• Invest in the alliance building process (Public Health Agency of Canada)
• Share leadership, accountability and rewards among partners (Public Health Agency of Canada)
• Capture the public's interest (Public Health Agency of Canada)
• Contribute to the health literacy of the public (Public Health Agency of Canada)

Government Ministries

• Generate political support and build on positive factors in the policy environment (Public Health Agency of Canada)
• 
  

Local Agencies

• Use a participatory process (New Zealand)

Schools/Neighbourhoods

• Ensure that initiatives involve most of the staff, students, and families in consultation and implementation (IUHPE Guidelines)