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It is clear that there is a need to pay attention to the contextual factors that will promote the broad adoption, successful implementation, and long-term sustainability of community-based environment and policy change. Reviews of both clinical and community-based interventions have shown that information about the intervention setting, how a program or policy is implemented, and how it is institutionalized are reported much less often than individual-level factors.1 Thus, as best practices for active living are identified, there is an equally important opportunity to identify ways to ensure that these best practices will be adopted, implemented, and maintained.
A key strength of the Active Living by Design (ALbD) program is its inclusion of a variety of types of communities. By purposively including both urban and rural communities, variation in climate and geographic locations, and both low- and moderate-income settings, this greatly enhances confidence that success is generalizable. Robustness of results across different types of communities is an important criterion for widespread public health impact, and the ALbD program receives high marks on this dimension.
The 5P model (preparation, promotion, programs, policy, and physical projects) used in ALbD2 should enhance adoption and implementation. Like the 5A’s model for smoking cessation and chronic illness self-management,3 this alliterative mnemonic facilitates understanding and reduces the complexity of multi-level interventions—one of Rogers’s key criteria for successful adoption.4 The 5P model should also help implementation as the framework serves as a reminder to community partners that it is important to address all of the Ps. It is clear from the papers in this issue that this framework was widely used by communities.
A first step to increasing the likelihood that the individuals who are reached (i.e., those who are exposed to the ALbD interventions) include those who could most benefit is through the strategic composition of the community partnership. Use of a multi-level socio-ecologic approach to identify those partners who represent, or have access to, the venues and organizations in which the target population(s) live, work, and play will greatly increase the likelihood of success. The variety of partners included in the ALbD communities, such as city planners, law enforcement, schools, residents, and neighborhood associations, bodes well for decreasing any skepticism that the partnership has a pre-determined agenda and for identifying issues and solutions that resonate with the target population.5
Another way to assure a broad reach for strategies that are ultimately sustained is to implement changes at the policy (e.g., zoning laws, school physical education policies) and environment (e.g., biking and pedestrian infrastructure) levels. While strategic use of programs is appropriate to build awareness, knowledge, and skills, assuring that organizations will continue to offer and finance them into the future is often challenging, particularly during tight times. Policies and environment changes, while more likely to be sustained once implemented, also require upkeep, enforcement, and periodic evaluation to assure they are effective. Although far fewer resources are required on an ongoing basis than for program activities, an unfunded policy mandate or a well-maintained trail that cannot be accessed without a car may not reach those most in need.
Of course, the real test of maintenance will be another 5 or 10 years to see if these communities have integrated ALbD goals, values, and activities into their vision of their communities. Encouraging shared leadership among partners, such as partner-led workgroups, will help to sustain partner engagement and foster adoption and maintenance of strategies beyond the grant.6 In addition, to the degree that partners are able to identify with and integrate the ALbD vision into their own organizations, the work of the partnership will continue even if the partnership is disbanded. It will be of interest to see how many of the partnerships established for ALbD have continued or evolved into something different. One example of how the 5P framework has already achieved maintenance and the related goal of generalization is the report that the framework has been used by ALbD communities for other grants and projects.
In reviewing the papers in this supplement7–21 to the American Journal of Preventive Medicine, we were struck by the diversity in lead agencies and partnership composition in ALbD projects. The ALbD program can apparently be structured in a way that fits the community, while still retaining its essential components.22 Over the long run, it will be interesting to see if partnerships that include residents at the outset, such as the Healthy Community Initiative in Buffalo, and share leadership and implementation responsibilities, such as Wyoming Valley, have better implementation or greater sustainability.2,7
Social justice is a key aspect of adoption—i.e., assuring that progressive programs and policies are adopted by a diverse spectrum of neighborhoods and organizations, not just those that are affluent or better resourced. It is encouraging that there are several examples, such as the Louisville housing authority, which serves low-income residents, that show this is not the case in ALbD.13
It is also clear that these communities have learned that leveraging resources and dollars is key to sustaining the momentum of the partnership’s activities. We were impressed that most communities have secured substantial additional funding that in several cases has even exceeded the amount of initial grant funding.
Successful implementation includes elements of Preparation and Promotion as well as opportunities for reporting immediate and interim outcomes. Regular reporting is important to sustaining momentum over the longer term. Clearly defining partnership goals and describing the planned implementation steps and timetable will allow for reporting of interim milestones. Strategic implementation of events and programs to engage, inform, and mobilize residents and partners while simultaneously beginning the multi-year work of implementing policy, systems, and environmental changes, should encourage continued involvement and enhance maintenance at both the setting and individual levels. Finally, documenting adaptations, challenges, and lessons learned, will help to spread best processes as well as practices.
One way to enhance maintenance is to integrate partnerships or activities into permanent structures. A great example of this is the Orlando partnership that became an official advisory council to the mayor.16 In addition, the occurrence of “spin-off” taskforces, particularly those that mobilize youth, such as the Student Coalition for Walkable Communities in Jackson where high school students are involved in environmental audits and letter writing campaigns, contributes to creating a norm of social participation and community empowerment.12,23,24
In summary, the ALbD program elements have been widely adopted and successfully implemented in diverse communities. Despite the recent economic downturn, the prognosis for sustainability is also reasonably good. A key factor predictive of long-term sustainability that will be addressed in a future AJPM supplement is ongoing evaluation and progress reporting. Since longer-term health outcomes may not be evident for years to come, documenting intermediate outcomes provides feedback to the partnership and an opportunity to celebrate accomplishments, make course corrections, and sustain momentum.5
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