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Complements to the Dissemination of Evidence-Based Programs
Anthony Biglan
Oregon Research Institute
Send correspondence to:
Anthony Biglan, Ph.D., Senior Scientist
Director, Center on Early Adolescence
Oregon Research Institute
1715 Franklin Boulevard
Eugene, Oregon 97403-1983
P: 541.484.2123/ F: 541.484.1108
Email: tony@ori.org
Acknowledgements
The National Cancer Institute (CA38273), the National Institute on Drug Abuse
(DA018760), and the National Institute on Alcohol Abuse and Alcoholism (AA014958)
provided financial support for the completion of the work on this manuscript. The author wishes
to thank Christine Cody for her editorial assistance and help in preparation of the paper.
Complements to evidence-based programs
2
Complements to the Dissemination of Evidence-Based Programs
Over the past 20 years, experimental research has produced a rich array of prevention and
treatment programs with proven benefit in affecting many psychological and behavioral
problems. Prevention and treatment researchers have created and tested numerous family
interventions to prevent or ameliorate both externalizing and internalizing problems.1; 2, 3
Research in schools shows that tobacco, alcohol, and other drug use can be prevented4 that
behavioral problems such as aggressive social behavior,5, 6 as well as depression7-9 can be
prevented. We have also seen progress on community interventions.10
These successes have naturally led to efforts to test the effectiveness of these programs
when front-line practitioners provide them or when populations different from the ones that
participated in the original research receive them.11 They have prompted increasing attention to
question of how to disseminate evidence-based programs widely and effectively. Exemplars of
this line of research include the Blueprints project,12 the Prosper project,13 the work of the
Norwegian Center of Child Behavioral Development,14 and the dissemination of the Nurse
Family Partnership.15
Research on the effectiveness and dissemination of evidence-based programs is vital to
the public health goal of reducing the incidence and prevalence of psychological and behavioral
problems in the population. These activities currently do not receive as much support as they
should receive, given the proven potential of evidence-based programs. It is crucial to extend the
efficacy of these programs to new populations and to develop and experimentally validate
strategies for testing and widely implementing effective programs. Doing so has the potential to
contribute to the first broad-scale reduction in the incidence and prevalence of psychological and
behavioral problems ever produced by intentional human intervention.
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However, if our ultimate goal is the reduction of the incidence and prevalence of
psychological and behavioral problems, it is important to understand the limitations of the
program dissemination strategy and to enumerate other, complementary strategies that can
contribute to this goal.
Limitations of the Program Dissemination Strategy
It is not hard to grasp the potential benefits of disseminating empirically supported
programs. By extrapolating their impact from experimental evaluations, one can estimate the
impact they would have if they were universally available. Even with considerable slippage, the
impact on public health would be huge. There are however, at least five limitations of program
dissemination strategies.
The first is that it is difficult to get programs implemented with fidelity by persons other
than the program developers.16 Research is underway that will surely improve strategies for
achieving fidelity of implementation. However, a second, related limitation is that, in order to
bring about broad adoption of programs, we must influence policymakers to allocate much more
money to them than is currently available. This is particularly a problem given the cost of
implementing many programs. Third, many problems of human behavior are relatively minor,
and do not merit implementation of a full-blown program.
A fourth limitation is that programs affect the behavior of an influence agent in the
targeted situation, but do not necessarily produce generalization of that agent’s skills to other
situations. For example, a teacher may encourage interaction in a substance use prevention
program,17 but not make use of this skill in other settings. Expecting people to develop and
generalize skills they learn in doing programs seems unrealistic, but in any case, it would seem
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useful to encourage behavior influence agents to use effective behavior influence skills in all of
their activities.
A fifth concern is that programs define circumscribed changes in people’s environment,
but do not necessarily affect other important aspects of those environments. For example, schoolbased drug abuse prevention programs attempt to alter skills, attitudes, perceptions, and social
relations relevant to drug abuse, but may have little impact on other important aspects of the
social environment such as students’ exposure to harassment.18 Parenting programs may alter the
family environment for young people in a more comprehensive fashion, but even they do not
necessarily produce generalized changes in family relationships.
In sum, relying solely on program dissemination to affect the incidence and prevalence of
psychological and behavioral problems is likely to produce a gradual improvement in public
health. Yet additional strategies for affecting wellbeing could accelerate these improvements.
Complementary Strategies for Affecting Human Wellbeing
The Pragmatics of Public Health
Public health research is inherently pragmatic. Once you embrace the goal of affecting
incidence and prevalence in a population, you become open to any practice that will contribute to
that goal. Efforts to deal with the problems of tobacco and alcohol use are good examples. The
prevalence of smoking among adults in the U.S. has dropped significantly in the past 50 years.19
Between 1965 and 2002, male smoking rates dropped from 51.6 to 25.2% and rates for women
declined from 34 to 20%. Smoking cessation and prevention research undoubtedly contributed to
this decline, but so did many other changes.19 One was extensive publicity about the harm of
smoking. Another was advocacy and implementation of laws and policies to change the norms
about smoking and influence many people to stop smoking. A third was the increase in taxes on
Complements to evidence-based programs
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cigarettes.{Chaloupka, 2002 30620 /id} A fourth was litigation that resulted in constraints on
tobacco company marketing practices, such as the Master Settlement Agreement, which ended
several effective cigarette-marketing practices.20
Similarly, the harmful consequences of alcohol use have been curtailed through extensive
advocacy that resulted in stronger laws and norms against drunk driving as well as an increase in
the drinking age, which significantly reduced alcohol related car crashes.21, 22 Here too, research
on interventions has been helpful, but the alcohol control movement never relied solely on
programs to achieve its outcomes.
These examples point to the value of considering all of the things that can affect
outcomes of concern. In the remainder of this paper, I outline some of the practices that will
complement the effort to disseminate evidence-based practices.
Creative Epidemiology
Sometime in the 1980s, Michael Daube coined the phrase “creative epidemiology” to
refer to effective ways of communicating the harm of smoking in order to motivate people to quit
and to support smoking control. Most tobacco control advocates would recognize the statement,
“The number of people killed by cigarette smoking in the U.S. is equivalent to the number of
people who would die if two Boeing 747s crashed killing everyone on board every day of the
year.” Publicity about the harm of smoking and about the perfidy of the tobacco companies 23
contributed to the massive changes in norms and behavior that have occurred in the U.S.19
Publicity has influenced many other health habits, including consumption of high fat foods24, 25
and screening for cancer.26 [find more examples!]
However, policymakers and the scientific community have been less inclined to use
creative epidemiology to affect most other psychological and behavioral problems that affect
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human wellbeing. Certainly, some public service announcements advocate reducing problems
such as child abuse and neglect, but there is nothing like the concerted, focused, and extensive
publicity that tobacco and alcohol advocates have mounted.
One reason for this may be that, unlike tobacco and alcohol use, which are circumscribed,
specific behaviors, the other problems are diverse and are not so easy to discuss. Would creative
epidemiology address each problem separately? For example, would there be separate publicity
about depression, antisocial behavior, anxiety, academic failure, etc? To some extent, this has
been the case. Creative epidemiology is not as easy to imagine for these problems because the
public health community has not drawn a clear and concise picture of the problems and has not
proposed a small number of things that might affect them. Epidemiological research has helped
to identify risk and protective factors for each problem and has guided the development of
interventions, but the results have not informed the public directly are what the problems are or
what can help to alleviate them.
Focusing on stressful and nurturing environments. A clear and concise picture is
emerging however. The generic features of psychological and behavioral problems have been
obscured by the fact that most etiological and intervention research has tended to focus on single
problems. Yet it is clear that most psychological and behavioral problems are inter-related, and
that the same set of environmental conditions influence them.1 Stressful family, school, work,
and neighborhood conditions increase the likelihood of depression, aggressive social behavior,
substance use, risky sexual behavior, and academic failure. Stressors that affect a significant
proportion of the population in the U.S. include poverty, substance abuse, illness, and aversive
interactions with others.
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These conditions make coercive interactions among family members more likely.
Patterson and his colleagues have shown that aggressive and uncooperative behavior develops
because of coercive interactions among family members and that such behavior leads to peer and
teacher rejection, academic failure, and the formation of deviant peer groups. Coercive family
processes also underpin depressive social behavior. 27, 28
At the same time, examination of the contents of evidence-based family and school
interventions show that their generic features involve nurturance. Parents and teachers learn to
minimize aversive behavior toward other family members, richly reinforce desirable behavior,
and accept others’ frustrating behavior rather than responding to it negatively. 29,30
In short, it is consistent with the evidence to say that public health will benefit from
increasing the proportion of families and schools that are nurturing. Rather than having to tell the
public about every problem and the unique risk factors for that problem, we may be able to affect
the range of psychological and behavioral problems by advocating for nurturance in all the
environments of society.
Think about what would happen if the public health agencies of government and
advocacy organizations came together around a set of simple messages about the need to
minimize stress in families and schools and maximize nurturance. Creative epidemiology could
encourage family members to understand that being a bit gentler toward one’s children is good
for everyone. It would empower those who believe in nurturance to advocate for it with family
members, friends, co-workers, and policymakers. It would focus local policymakers on the
importance of strengthening families through policies and programs. It would not detract from
the dissemination of evidence programs; it would increase demand for them.
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Kernels
As understanding of the value of nurturance permeates the population, there will be a
growing demand for simple tools that can help families, schools, neighborhoods, and work
places become more nurturing. A mother who learns the value of reinforcing her daughter’s
cooperation may not need or may not have available a program on parenting. However, she
might benefit from simple procedures that would facilitate her being reinforcing.
Embry31 coined the term “kernels” to designate any simple behavior influence procedure
shown through experimental evaluation to affect a behavior. Examples include time out, praise
notes, and “beat the timer” (in which a child gets a reward for finishing something before the
timer goes off). Embry and Biglan32 have identified over 50 kernels and argue that they can
usefully supplement dissemination of more complex programs.
Although not explicitly employing the kernels concept, the recent work of Prinz and
Sanders 33 on the Positive Parenting Program (Triple P) involved a similar approach. In addition
to offering intensive parenting programs, they made advice and information about parenting
widely available to families in South Carolina counties randomly assigned to receive the
intervention. The result was one of the few examples of a family intervention that affected the
incidence of child abuse in an entire population.
Monitoring Systems
Imagine that every community routinely assessed the prevalence of psychological and
behavioral problems as well as the most important risk factors for those problems. Increasingly,
communities and entire states are implementing such systems.34 The Communities That Care
system provides such data to communities and guides them to select interventions that have
proven benefit in affecting key risk and protective factors. In a randomized trial involving 24
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communities, CTC communities were lower than controls on targeted risk factors and on a
measure of delinquency initiation.35
In the context of creative epidemiology, community-monitoring systems could contribute
to the reduction of problems. They would influence the evolution of more effective practices as
communities retained practices associated with lower rates of problems and abandoned or
modified those which did not seem to be affecting the problem. This is why it is the policy of the
Society for Prevention Research to promote monitoring systems. It should be a high priority for
funding agencies to contribute to the development and further evaluation of such systems.
If this seems like an enormous undertaking, remember that most societies systematically
collect hundreds of measures on the performance of the economy and use those measures to
guide economic policy. These systems are fundamental to the improvements in economic
management in the past 50 years in the United States and in most other developed countries.36
Policy
As understanding of the toxic effects of stressful environments grows, it will become
easier to direct public policymaking to the prevention or modification of stressful environments
and to the promotion of nurturance. Perhaps the single most important area needing policy
involves poverty.
Poverty is a well-established risk factor for coercive relationships in families,37
inadequate parenting,38 and internalizing and externalizing problem of children.39 Policies that
can reduce family poverty include Medicaid, the Earned Income Tax Credit (EITC), Temporary
Assistance to Needy Families, food stamps, federal housing subsidies, the School Lunch
Program, and WIC. 40 Reducing family poverty can reduce children’s externalizing and
internalizing problems 39 and improve their academic achievement.41,42 Since the U.S. has the
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highest rate of child poverty among 25 developed nations,43 implementing policies that reduce
family poverty may be the single most important action we can take to prevent psychological and
behavioral problems.
Policies should also support the dissemination of evidence-based programs. Increasingly,
federal agencies require that evidence-based programs be implemented,44 although the agencies
vary in the criteria they use to identify programs. Development of a standard policy45 and efforts
to get it adopted by state and local agencies would increase the demand for policies.
Perhaps more important are policies that provide the funds to implement and maintain
evidence-based programs. Requiring schools and family service agencies to use evidence-based
programs is a coercive policy that is likely to be resisted, unless it is accompanied by the
resources for training, quality monitoring, and maintenance.14
If creative epidemiology resulted in widespread understanding of the need to reduce
stressful or aversive stimulation, it could ignite a review of all of the punitive policies we have in
our society. From zero tolerance policies to mandatory minimum sentences, American society is
rife with punishment. The fundamental move of parenting interventions is to reduce harsh and
inconsistent punishment and increase positive reinforcement. In schools, Mayer et al.46 have
shown that schools with many rules and high levels of punishment have greater vandalism and
rule violation. This is exactly what coercion theory would predict. Not surprisingly, therefore,
research on Positive Behavior Support in schools has shown the benefit of reducing such
punishment and increasing positive reinforcement.47
Public policy could set greater limits on the use of punishment. For example, 21 states
still allow corporal punishment in schools 48 and detention, suspension, and criticism are still
used more than any empirical evidence would justify.30 Policies could require the
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implementation of systems of positive reinforcement in schools as an alternative to punishment.
Such a policy was recently adopted by the Los Angeles Unified Schools (Horner, Sept. 7, 2008;
[his presentation at ABAI ].
Policies could also increase reinforcement. For example, as part of the empirically
evaluated PeaceBuilders program,49 Embry and colleagues were able to encourage local TV
stations to recognize a PeaceBuilder child in every school in the community every day. School
policy could require systems offering much higher levels of public recognition of exemplary
behavior than currently occurs.
Two types of research are necessary to develop effective policies. First, we need studies
that experimentally evaluate specific policies. As with programs, we cannot assume that policies
will have their intended impact. Second, research must occur on how to influence policymaking.
For example, my claim that creative epidemiology will influence policymaking could be put to
the experimental test.
In Addition to Dissemination
Research on the effective dissemination of evidence-based practices is vital in translating
existing preventive evidence into population-wide benefits. However, a comprehensive public
health approach to reducing the incidence and prevalence of psychological and behavioral
problems must include additional strategies.
Just as smoking declined as people came to understand how harmful the behavior is,
widespread understanding of the numerous harmful effects of stressful or aversive environments
could motivate many people in society to make family, school, work, and neighborhood
environments more nurturing. Research on creative epidemiology to make this understood could
Complements to evidence-based programs
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affect the prevalence of such environments, even in places where programs do not exist (or
where they remain undeveloped).
Kernels—simple empirically supported procedures for influencing behavior—could
facilitate the spread of nurturing practices and the abandonment of harsh and inconsistent
punishment.
The implementation of monitoring systems could focus policymakers and citizens on
how well communities are doing in trying to reduce aversive environments and increase the
prevalence of nurturing environments. Such systems would foster the evolution of better
practices as evidence prompted the abandonment of ineffective practices and the retention of
more beneficial ones.
Finally, once the generic features of prosocial and coercive environments are clear,
policymakers will help to develop, implement, and evaluate policies based on the impact of those
policies in reducing aversive environments and increasing more nurturing ones.
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