1. Introduction
2. Definition of terms
3. Why is this Important? (Describe scope of action possible with this intervention, including a discussion of potential outputs)
4. Key aspects, elements of and approaches to the intervention
5. Research and reports on the use of evidence-based implementation models on health, specific aspects of health/social development/learning/disparities or health/social behaviours (based on research reviews, landmark studies)
6. Examples of the use evidence-based implementation strategies (successful case studies)
7. Successful Strategies in evidence-based implementation
8. Identify and discuss challenges to using evidence-based implementation models and ways to address those challenges
9. Recommendations for National Agencies/Federal Departments, Provincial/State/Territorial Ministries, Local School Boards/Authorities/Agencies, Schools/Clinics/Local Professionals
10. Provide links to key research references and reports/resources

• Distribution of a Program: This limited strategy of the distribution of a resource, educational program or guidelines simply sends the materials to a set of intended audiences in a manner that is convenient to them, preferably using a means that does not reply on an intermediary to transmit the information further. Basic communications strategies such as timing of the distribution, the packaging, personalized mailing lists, adaptation of the material to suit the segmented audiences and other basic elements should be considered.
  

• Promotion of/Publicity about a Program This second level of activity includes an ongoing publicity function to support or encourage distribution. This level of activity will have someone assigned to respond to inquiries. This person or agency will be hired by the originating organization and is made responsible as well as given time and funding to publicize the availability and desirable features of the resource. This ongoing promotion/publicity strategy also requires an ongoing budget or staff time to frequently publicize the resource, in appropriate and selected media, in a format suitable to the audiences, using spokespersons recognized as being credible by those audiences, with messages crafted to respond to current awareness, knowledge, perceptions and concerns of the audiences relative to the issue being addressed by the resource.
  

• Dissemination: A dissemination strategy crosses the line into providing “customer support” but does not hire new staff or provide ongoing funding for new staff to diffuse or implement the educational resource or policy/program resource. Instead, a dissemination strategy distributes and promotes a new resource within the context of existing systems, agencies, communities or situations and persuades an existing organization or individual to use the new resources in their own work. In effect, a dissemination strategy relies on others becoming a champion and change agent on behalf of the new resource, innovation or idea. The benefits of the new resource would have to be not only understood and accepted by the partners, but the strategic advantages of the resource or in working with the publishers of the new resource would have to be apparent to the potential “champions”. These new partners would have to have the sustained resources necessary to diffuse or implement the resource.
  

• Diffusion: Everett Rogers defines diffusion as the process by which an innovation is communicated through certain channels over time among the members of a social system. Rogers' definition contains four elements that are present in the diffusion of innovation process. The four main elements are:

• (1) innovation - an idea, practices, or objects that is perceived as new by an individual or other unit of adoption. 2) communication channels - the means by which messages get from one individual to another. (3) time - the three time factors are: (a) innovation-decision process (b) relative time with which an innovation is adopted by an individual or group. (c) innovation's rate of adoption. (4) social system - a set of interrelated units that are engaged in joint problem solving to accomplish a common goal. In his later works, Rogers described the differences between early and later adopters of an innovation and made suggestions such as initially focusing on the early adopters in order to create momentum. One of the essential differences between a diffusion and dissemination strategy is the depth of penetration into the systems or communities it is intended to reach. A diffusion strategy recognizes that in most situations and systems such as school systems, there are several layers involved in accepting the change or program. Different approaches and explanatory materials need to be created for the different levels and sustained efforts need to be brought to bear over a number of years to achieve the desired effect. A second difference is that the resource is created after the recipients have identified the need for the program or new practice and are consequently looking for tools and techniques to help them implement the change.
  
  
• Implementation/Evaluation/Evolution In this almost final stage of change, local agents have adopted the need for change and are implementing the innovation in their daily work. A significant difference between diffusion and implementation is the feedback loop whereby the impact and the process of the innovation is subject to evaluation. These evaluation results are then used to evolve or revise the innovation. The following diagram illustrates this feedback loop.
  
  
• Institutionalization: This final stage of the process indicates that the program has become sustainable because it is now considered part of the core business of the organization. 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.
  
  
• Others have included similar criteria or characteristics of institionalized programs. These include changes in the routines, core procedures and staffing structures of an organization (Ohly, et al, 2006; Pluye et al, 2004, Hoy and Sweetland, 2001) .
  
  
  

• They base their work on a proven theories on diffusion, organizational and professional change
• They select or develop a planned diffusion/ implementation planning tool that has been evaluated and proved to be effective
• They use active and ongoing staff involvementbased on a theory or model of staff development/teacher education
• They use a variety of planning and training tools and processes including collegial/supervisory mentoring and coaching, collaborative work teams, communities of practice, formal and informal knowledge networks, workshops, email, online work spaces, conference calls and more
• They use a variety of consultation, evaluation and reporting procedures
• They use active parent involvement that is based on a theory or model of parent involvement in schools and health promotion/social development
  
• They engage youth, informally or formally, in the development, operation and evaluation of the program in a manner that that is consistent with research and knowledge on effective youth engagement
• They involve community-based and voluntary organizations through consultations and advisory committees.
  
• They use data (surveys, administrative data, reports, consultations etc ) to identify the problem, select the program, assess implementation and evaluate outputs
• They engage experts in the development and evaluation of their efforts

• diffusion of innovations,
• organizational development
• systems change, capacity-building and continuous improvement
• health promotion planning
• educational reform and improvement
• community development
• management and leadership theories
  
• staff development theory

• Diffusion of Innovations (Rogers) theory describes how innovations are adopted within systems. Understanding the different stages of adoption, implementation and evolution help to focus resources on key steps in a timely manner. One of the best applications of this theory to school health was done by Kolbe & Iverson (1981). This early example described five basic stages in the implementation process within a school board.
  
  

  1.	Mobilization	Where those who are associated with a service or program become aware of how that service could be improved.
  2.	Adoption	Where the decision-makers governing that service or program make a commitment to pursue a given course of action.
  3.	Implementation	Where the course of action is put into practice.
  4.	Maintenance	When the practice is continued.
  5.	Evolution	When the new practice changes qualitatively or quantitatively.

  
  Clarke (1994) notes that some innovations take the world by storm (Sony Walkman and Apple Ipod), while others lie dormant for decades (fax machines). Most innovations, however, start slowly then become adopted quickly, with a slow-down in the later stages. He presents similar stages through which an innovation occurs. They include:
  • Knowledge about the innovation
  • Persuasion to form a favourable attitude
  • Decision to adopt
  • Implementation of the innovation
  • Confirmation of its value.
    
    
  Clarke also discusses the important characteristics of the innovation that will affect implementation. They include:
  • Relative advantage (perceived and real)
  • Compatability with existing values, experiences, needs
  • Complexiity and difficulty in using it
  • Trialability – degree to which it can be tried on a limited basis
  • Observability – the visibility of its results.
    
    
  There are also different categories of adopters, including:
  • Innovators – venturesome individuals
  • Early adopters – respectable members who begin the change
  • Early majority – deliberate decision-makers who are persuaded
  • Late majority – skeptical people who go along
  • Laggards – traditional people who may never adopt the change.
    
    
  There are also important roles played in the innovation process by several people. These include:
  • Opinion leaders – who have informal or formal influence over others
  • Change agents – who influence decisions and mediate between the change and the system
  • Change aides – who complement the change agent by having intensive contact with the adopters.
    
    
  The change agent functions include:
  • To develop a need for change within the system
  • To establish an information-exchange relationship
  • To diagnose problems in adopting the innovation
  • To create an intent for change among adopters and within the system
  • To help the adopter translate this intent into partial action
  • To stabilize the adoption prevent discontinuance
  • To shift adopters to self-reliance.
  
  
  Characteristics of the Innovation/Approach and Implementation
  
  
  Kolbe and Iverson (1981) describe how the important features of an innovation or reform will determine its potential
  

  Relative Change	The different elements of relative advantage are economic costs (purchase value), usefulness (degree to which it meets the real needs of the group adopting it and pay-off time (the length of time it takes to realize results.
  Impact on Social Relations	The positive or negative influence on social relationships within the target system as well as between the target system and important outside groups.
  Divisibility	The degree to which the innovation can be implemented on a limited scale or in planned stages.
  Reversibility	The greater the ease with which an innovation may be discontinued, the more likely it will be tried.
  Complexity	The greater the complexity, the less likely it will be tried.
  Compatibility	The congruence of the innovation with the technical, psychological, sociological and cultural attributes of the situation.
  Communicability	The ease with which the information can be disseminated and understood.
  Time	The length of time required to introduce or implement the innovation.
  Risk and Uncertainty	The personal and institutional risk inherent in introducing the innovation.
  Commitment	The greater the commitment required to adopt and implement the innovation (i.e. the greater amount of time, money or human resources), the less likely the innovation will be implemented.
  Capacity for Successive Modification	The capacity for the innovation to be updated.

  
  

Learning Organization Theory

• Organizations are products of the ways that people in them think and interact;
• To change organizations for the better, you must give people the opportunity to change the ways they think and interact;
• No one person, including a highly charismatic teacher or CEO, can train or command someone else to alter their attitudes, beliefs, skills, capabilities, perceptions, or level of commitment.
• Instead, the practice of organizational learning involves developing and taking part in tangible activities that will change the way people conduct their work. Through these new governing ideas, innovations in infrastructure, and new management methods and tools people will develop an enduring capability for change.

• PRECEDE/PROCEDE (Green) Green’s planning and action framework has been used extensively in health promotion and school health promotion. His pre-disposing, reinforcing and enabling factors are earlier versions of the risk and protective factors now commonly discussed in population health.

• Concerns-Based Adoption Model (Hord)
  The CBAM approach to educational change has been used extensively in North America and promoted by the Association for Supervision and Curriculum Development, the prominent senior educational leadership group in the United States and other countries.

• Social Learning as basis for Teacher Development
  The early work that Levinson-Gingiss(1989) and others have done on teacher training has been applied by Han & Weiss (2005) on teacher training for school mental health programs. Kealey (2000) has described the teacher training process as behaviour change. Gingiss (1995) explains how teacher training needs to follow this social learning model if health teachers are to be well engaged.
• Halbert, et al. (1993) have described some of the training required to help public health nurses to develop and implement population-based health promotion strategies. This program was implemented in the Hamilton-Wentworth Health Unit in Ontario. A series of workshops addressed the structural and systemic barriers to population health practices.

• 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 (complexity, reversability, costs, familiarity etc) will affect adoption, implementation and institutionalization.
• Linking the innovation directly to the core mandate of the organization and to current priorities is critical
• 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.

• 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.

• All programs, policies and services should be evaluated regularly (American NGOs)

• Generate data through mixed research methods (Public Health Agency of Canada)

• strategies should be developed to support local agencies and schools (World Health Organization,)

• Identify and promote an evidence-based list of promising practices and strategies as part of a work force development plan. (Centers for Disease Control US)

• Use shared decision-making and participation to garner support for SH programs (Depts of Health & Education, Queensland, Australia, World Health Organization )
• Local agencies should evaluate their programs and partnerships on a regular basis. (National Healthy Schools Program, England

• Use a structured, planned process to engage school stakeholders (Schools for Health in Europe, Depts of Health & Education, Queensland, Australia)
  
• Use modern staff development techniques such as mentoring, professional reflection, communities of practice to promote professional and systems change (American NGOs, )
  
• Programs should be evaluated on a regular basis using appropriate evaluation procedures and methods (American NGOs, Centers for Disease Control, US, National Healthy Schools Program, England