Advancing the Science and Application of Implementation Science to Promote Health Equity: Commentary on the Symposium.

There has been an increasing focus on making health equity a more explicit and foundational aspect of the research being conducted in public health and implementation science. This commentary provides an overview of five reviews in this Annual Review of Public Health symposium on Implementation Science and Health Equity. These articles reflect on and advance the application of core implementation science principles and concepts, with a focus on promoting health equity across a diverse range of public health and health care settings. Taken together, the symposium articles highlight critical conceptual, methodological, and empirical advances in the study designs, frameworks, and approaches that can help address equity considerations in the use of implementation science in both domestic and global contexts. Finally, this commentary highlights how work featured in this symposium can help inform future directions for rapidly taking public health to scale, particularly among systemically marginalized populations and communities.

Challenges and Opportunities for Paving the Road to Global Health Equity Through Implementation Science.

Implementation science focuses on enhancing the widespread uptake of evidence-based interventions into routine practice to improve population health. However, optimizing implementation science to promote health equity in domestic and global resource-limited settings requires considering historical and sociopolitical processes (e.g., colonization, structural racism) and centering in local sociocultural and indigenous cultures and values. This review weaves together principles of decolonization and antiracism to inform critical and reflexive perspectives on partnerships that incorporate a focus on implementation science, with the goal of making progress toward global health equity. From an implementation science perspective, wesynthesize examples of public health evidence-based interventions, strategies, and outcomes applied in global settings that are promising for health equity, alongside a critical examination of partnerships, context, and frameworks operationalized in these studies. We conclude with key future directions to optimize the application of implementation science with a justice orientation to promote global health equity.

Cumulative Stress Across the Life Course and Biological Aging in Adulthood.

OBJECTIVE: Psychosocial stressors have been linked with accelerated biological aging in adults; however, few studies have examined stressors across the life course in relation to biological aging. METHODS: In 359 individuals (57% White, 34% Black) from the Child Health and Development Studies Disparities study, economic (income, education, financial strain), social (parent-child relations, caretaker responsibilities) and traumatic (death of a sibling or child, violence exposure) stressors were assessed at multiple time points (birth and ages 9, 15, and 50 years). Experiences of major discrimination were assessed at age 50. Life period stress scores were then assessed as childhood (birth-age 15 years) and adulthood (age 50 years). At age 50 years, participants provided blood samples, and DNA methylation was assessed with the EPIC BeadChip. Epigenetic age was estimated using six epigenetic clocks (Horvath, Hannum, Skin and Blood age, PhenoAge, GrimAge, Dunedin Pace of Aging). Age acceleration was determined using residuals from regressing chronologic age on each of the epigenetic age metrics. Telomere length was assessed using the quantitative polymerase chain reaction-based methods. RESULTS: In linear regression models adjusted for race and gender, total life stress, and childhood and adult stress independently predicted accelerated aging based on GrimAge and faster pace of aging based on the DunedinPace. Associations were attenuated after adjusting for smoking status. In sex-stratified analyses, greater childhood stress was associated with accelerated epigenetic aging among women but not men. No associations were noted with telomere length. CONCLUSIONS: We found that cumulative stressors across the life course were associated with accelerated epigenetic age, with differences by sex (e.g., accelerated among women). Further research of this association in large and diverse samples is needed.

Community Engagement in Behavioral Medicine: A Scoping Review.

BACKGROUND: Behavioral medicine has made key contributions toward improving health outcomes. Engaging community partners in research is critical to addressing persistent health inequities. The aim of this scoping review was to explore how researchers engaged community partners within the field of behavioral medicine research from 2005 to 2023. METHOD: Publication databases and gray literature were searched for research that engaged community partners to address questions relevant to behavioral medicine. Articles were screened by title and abstract, and then by full text. Articles meeting the inclusion criteria were coded using the framework provided by the Engagement Navigator to identify engagement approaches, methods, and tools and when they were used during the research. RESULTS: Of 1486 articles initially identified, 58 met the inclusion criteria. Most articles used well-known approaches (e.g., community-based participatory research; 67%), methods (e.g., advisory committees; 59%), and tools (e.g., interviews; 41%), and engaged with healthcare service providers (62%) and/or patients (53%). Community partners were most often included in research planning and design (79%), and less often in dissemination (45%). CONCLUSION: Community engagement has considerable potential to address health inequities. Our assessment of the approaches, methods, and tools used by behavioral medicine researchers to engage with a diverse range of community partners points toward promising strategies for enhancing the impact of community engagement. Researchers should incorporate explicit descriptions of community engagement strategies in publications, an outcome that could be facilitated by clear publishing guidelines, structured reporting tools, and clear messaging from funders about the value of community engagement in behavioral medicine research.

Enhancing Impact: A Call to Action for Equitable Implementation Science.

Despite investments in evidence-based interventions and Implementation Science, most evidence-based interventions are not widely or routinely adopted, delivered, or sustained in many real-world community and healthcare settings. This gap is even greater in settings and populations experiencing numerous social and structural barriers to health, with important implications for persistent patterns in health inequities. In this Viewpoint, as part of a Special Issue on Advancing the Adaptability of Chronic Disease Prevention and Management through Implementation Science, we outline seven calls to action for the field of Implementation Science, with the goal of encouraging researchers, practitioners, and funders to be more intentional and accountable in applying Implementation Science to have greater impact on promoting health equity. Calls to action include (1) enhance public health, community, and multi-sectoral partnerships to promote health equity and equitable implementation; (2) revisit and build the evidence base needed to promote health equity and impact at multiple levels; (3) prioritize focus on policy development, dissemination, and implementation; (4) be agile and responsive in application of Implementation Science frameworks, processes, and methods; (5) identify and redefine meaningful metrics for equity and impact; (6) disseminate scientific evidence and research to a diverse range of partners and potential beneficiaries; and (7) extend focus on de-implementation, mis-implementation, and sustainability which are central to enhancing health equity. Additionally, we outline why a focus on prevention and public health is essential to making progress towards health equity in Implementation Science, summarize important advancements that the field has made towards making equity more foundational, and pose important research questions to enhance equitable impact of work in this area.

Breast cancer worry, uncertainty, and perceived risk following breast density notification in a longitudinal mammography screening cohort.

BACKGROUND: Dense breast notification (DBN) legislation aims to increase a woman's awareness of her personal breast density and the implications of having dense breasts for breast cancer detection and risk. This information may adversely affect women's breast cancer worry, perceptions of risk, and uncertainty about screening, which may persist over time or vary by sociodemographic factors. We examined short- and long-term psychological responses to DBN and awareness of breast density (BD). METHODS: In a predominantly Hispanic New York City screening cohort (63% Spanish-speaking), ages 40-60 years, we assessed breast cancer worry, perceived breast cancer risk, and uncertainties about breast cancer risk and screening choices, in short (1-3 months)- and long-term (9-18 months) surveys following the enrollment screening mammogram (between 2016 and 2018). We compared psychological responses by women's dense breast status (as a proxy for DBN receipt) and BD awareness and examined multiplicative interaction by education, health literacy, nativity, and preferred interview language. RESULTS: In multivariable models using short-term surveys, BD awareness was associated with increased perceived risk (odds ratio (OR) 2.27, 95% confidence interval (CI) 0.99, 5.20 for high, OR 2.19, 95% CI 1.34, 3.58 for moderate, vs. low risk) in the overall sample, and with increased uncertainty about risk (OR 1.97 per 1-unit increase, 95% CI 1.15, 3.39) and uncertainty about screening choices (OR 1.73 per 1-unit increase, 95% CI 1.01, 2.9) in Spanish-speaking women. DBN was associated with decreased perceived risk among women with at least some college education (OR 0.32, 95% CI 0.11, 0.89, for high, OR 0.50, 95% CI 0.29, 0.89, for moderate vs. low risk), while those with a high school education or less experienced an increase (OR 3.01, 95% CI 1.05, 8.67 high vs. low risk). There were no associations observed between DBN or BD awareness and short-term breast cancer worry, nor with any psychological outcomes at long-term surveys. CONCLUSIONS: Associations of BD awareness and notification with breast cancer-related psychological outcomes were limited to short-term increases in perceived breast cancer risk dependent on educational attainment, and increases in uncertainty around breast cancer risk and screening choices among Spanish-speaking women.

Qualitative Research Methods in Chronic Disease: Introduction and Opportunities to Promote Health Equity.

Public health research that addresses chronic disease has historically underutilized and undervalued qualitative methods. This has limited the field's ability to advance (a) a more in-depth understanding of the factors and processes that shape health behaviors, (b) contextualized explanations of interventions' impacts (e.g., why and how something did or did not work for recipients and systems), and (c) opportunities for building and testing theories. We introduce frameworks and methodological approaches common to qualitative research, discuss how and when to apply them in order to advance health equity, and highlight relevant strengths and challenges. We provide an overview of data collection, sampling, and analysis for qualitative research, and we describe research questions that can be addressed by applying qualitative methods across the continuum of chronic disease research. Finally, we offer recommendations to promote the strategic application of rigorous qualitative methods, with an emphasis on priority areas to enhance health equity across the evidence generation continuum.

Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study.

Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.

School-level factors associated with the sustainment of weekly physical activity scheduled in Australian elementary schools: an observational study.

BACKGROUND: We aimed to: (1) identify school-level factors associated with the sustainment of weekly physical activity (PA) scheduled in elementary schools following withdrawal of effective implementation support; and (2) determine teacher's perceived usefulness of suggested strategies for sustaining the scheduling of weekly PA. METHODS: A secondary exploratory analysis was employed of data from the intervention arm (n = 31 schools) of a randomised controlled trial. Self-report survey data from 134 classroom teachers in New South Wales, Australia, collected following withdrawal of initial implementation support (follow-up T1) and six-months following completion of support (follow-up T2) were used. The outcomes of sustainment of weekly overall PA and energisers (short classroom PA breaks) scheduled were measured via teachers' completion of a daily activity logbook, with results presented as the difference in mean minutes of PA and energisers scheduled at T1 and T2. An adapted version of the Program Sustainability Assessment Tool (PSAT) was used to measure capacity for program sustainability across seven key domains at follow-up T2. Linear mixed regressions were conducted to evaluate associations between school-level sociodemographic characteristics (e.g., school size, remoteness, and type), teacher-reported school factors (i.e., seven adapted PSAT domains) and the sustainment of PA and energisers scheduled across the school week. Perceived usefulness of 14 proposed sustainability strategies was measured via the teacher survey at follow-up T2 and reported descriptively. RESULTS: No school-level factor was statistically associated with the sustainment of overall weekly PA or energisers scheduled. Teacher-reported factors in two PSAT domains - 'strategic planning' and 'program evaluation' were statistically negatively associated with the sustainment of weekly energisers scheduled (- 6.74, 95% CI: - 13.02; - 0.47, p = 0.036 and - 6.65, 95% CI: - 12.17; - 1.12, p = 0.019 respectively). The proposed support sustainability strategy - 'provision of PA equipment packs that enable energisers or integrated lessons' was perceived useful by the most teachers (85%). CONCLUSIONS: Further research is required to explore additional contextual-specific, and end-user appropriate factors associated with schools' sustainment of weekly PA scheduled. This will help accurately inform the development of strategies to address these determinants and support the sustainment and long-term benefits of school-based health interventions more broadly.

Assessing researchers' capabilities, opportunities, and motivation to conduct equity-oriented dissemination and implementation research, an exploratory cross-sectional study.

BACKGROUND: A recent paradigm shift has led to an explicit focus on enhancing health equity through equity-oriented dissemination and implementation (D&I) research. However, the integration and bidirectional learning across these two fields is still in its infancy and siloed. This exploratory study aimed to examine participants' perceived capabilities, opportunities, and motivations to conduct equity-oriented D&I research. METHODS: We conducted an exploratory cross-sectional survey distributed online from December 2020 to April 2021. Participants were recruited at either D&I or health disparities-oriented conferences, meetings, through social media, or personal outreach via emails. Informed by the Capability, Opportunity, and Motivation Model (COM-B), the survey queried respondents about different aspects of engaging in and conducting equity-oriented D&I research. All analyses were conducted in SPSS Version 27.0. RESULTS: A total of 180 participants responded to the survey. Most participants were women (81.7%), white (66.1%), academics (78.9%), and faculty members (53.9%). Many reported they were advanced (36.7%) or advanced beginners (27.8%) in the D&I field, and a substantial proportion (37.8%) reported being novice in D&I research that focused on health equity. Participants reported high motivation (e.g., 62.8% were motivated to apply theories, models, frameworks for promoting health equity in D&I research), but low capability to conduct equity-oriented D&I research (e.g., 5% had the information needed for promoting health equity in D&I research). Most participants (62.2%) reported not having used measures to examine equity in their D&I projects, and for those who did use measures, they mainly used individual-level measures (vs. organizational- or structural-level measures). When asked about factors that could influence their ability to conduct equity-oriented D&I research, 44.4% reported not having the skills necessary, and 32.2% stated difficulties in receiving funding for equity-oriented D&I research. CONCLUSIONS: Study findings provide empirical insight into the perspectives of researchers from different backgrounds on what is needed to conduct equity-oriented D&I research. These data suggest the need for a multi-pronged approach to enhance the capability and opportunities for conducting equity-oriented D&I work, such as: training specifically in equity-oriented D&I, collaboration between D&I researchers with individuals with expertise and lived experience with health equity research, funding for equity-oriented D&I research, and recognition of the value of community engaged research in promotion packages.

Experience of a National Cancer Institute-Designated Community Outreach and Engagement Program in Supporting Communities During the COVID-19 Pandemic.

Coronavirus disease of 2019 (COVD-19) continues to disrupt cancer care delivery efforts and exacerbate existing health inequities. Here we describe the impact of COVID-19 on community outreach organizations partnering with a National Cancer Institute-designated Community Outreach and Engagement (COE) office in New York City (NYC) and lessons learned from these experiences. Between July and September of 2020, we conducted 16 semi-structured interviews with community key-informants to validate and inform efforts to support community organizations in response to COVID-19. Key-informants represented organizations performing a broad range of health and cancer care activities serving historically underserved, low-income, marginalized communities of color in NYC. All interviews were recorded, transcribed, and analyzed using rapid qualitative approaches. We summarize our response to challenges raised by partnering organizations. Themes included the impact of COVID-19 on communities served, challenges faced by organizations, and solutions to address COVID-19 related challenges. The COE and community organizations had to shift priorities and adapt engagement efforts to address the more urgent needs of the community (e.g., emotional distress, food insecurity). COVID-19 disrupted traditional community engagement activities for cancer outreach-calling for creativity and innovation in the community engagement process and shift in priorities. The COE responded by maintaining ongoing dialogue with community partners, by being flexible in scope/priorities beyond cancer prevention and control, and by providing education, outreach, fundraising and other resources, and developing new partnerships to meet needs of community organizations and the populations they serve.

The pragmatic, rapid, and iterative dissemination and implementation (PRIDI) cycle: adapting to the dynamic nature of public health emergencies (and beyond).

BACKGROUND: Public health emergencies-such as the 2020 COVID-19 pandemic-accelerate the need for both evidence generation and rapid dissemination and implementation (D&I) of evidence where it is most needed. In this paper, we reflect on how D&I frameworks and methods can be pragmatic (i.e., relevant to real-world context) tools for rapid and iterative planning, implementation, evaluation, and dissemination of evidence to address public health emergencies. THE PRAGMATIC, RAPID, AND ITERATIVE D&I (PRIDI) CYCLE: The PRIDI cycle is based on a "double-loop" learning process that recognizes the need for responsiveness and iterative adaptation of implementation cycle (inner loop) to the moving landscapes, presented by the outer loops of emerging goals and desired outcomes, emerging interventions and D&I strategies, evolving evidence, and emerging characteristics and needs of individuals and contexts. Stakeholders iteratively evaluate these surrounding landscapes of implementation, and reconsider implementation plans and activities. CONCLUSION: Even when the health system priority is provision of the best care to the individuals in need, and scientists are focused on development of effective diagnostic and therapeutic technologies, planning for D&I is critical. Without a flexible and adaptive process of D&I, which is responsive to emerging evidence generation cycles, and closely connected to the needs and priorities of stakeholders and target users through engagement and feedback, the interventions to mitigate public health emergencies (e.g., COVID-19 pandemic), and other emerging issues, will have limited reach and impact on populations that would most benefit. The PRIDI cycle is intended to provide a pragmatic approach to support planning for D&I throughout the evidence generation and usage processes.

Telehealth in a Washington, DC African American Religious Community at the Onset of COVID-19: Showcasing a Virtual Health Ministry Project.

The COVID-19 pandemic, with its disproportionate health and social-economic effects on the African American community, mandates bold new models to ensure that vulnerable communities receive maximum support and services. This article highlights a social work practice innovation model adapted from a traditional social work casework model. A group of multidisciplinary leaders strategized about ways to meet the needs of older African-American adults as many traditional government agencies were not sending staff into the community due to COVID-19. The result birthed a faith-based virtual health ministry.Using a faith-based virtual health ministry, church lay leaders and other professionals partnered with Master of Social Work (MSW) level social workers using a telehealth platform with technology tools to assist shut-in older adults in Washington, DC. The project uses a structured, coordinated care telehealth support model for a marginalized population. Telehealth within the rubric of healthcare models has not been demonstrated in African American communities, particularly older adults. Meeting the needs of shut-in older adults and marginalized groups within the COVID-19 pandemic may show innovation that can be translational for local governments and traditional safety net providers within a social work milieu.

What Is Dissemination and Implementation Science?: An Introduction and Opportunities to Advance Behavioral Medicine and Public Health Globally.

There has been a well-documented gap between research (e.g., evidence-based programs, interventions, practices, policies, guidelines) and practice (e.g., what is routinely delivered in real-world community and clinical settings). Dissemination and implementation (D&I) science has emerged to address this research-to-practice gap and accelerate the speed with which translation and real-world uptake and impact occur. In recent years, there has been tremendous development in the field and a growing global interest, but much of the introductory literature has been U.S.-centric. This piece provides an introduction to D&I science and summarizes key concepts and progress of the field for a global audience, provides two case studies that highlight examples of D&I research globally, and identifies opportunities and innovations for advancing the field of D&I research globally.

Do Alternative Cooling Methods Have Effective Cooling Rates for Hyperthermia Compared With Previously Established CWI Cooling Rates?

Clinical Scenario: In the last few years, there have been several studies examining alternative cooling strategies in the treatment of exertional heat stroke (EHS). Morbidity and mortality with EHS are associated with how long the patient's core body temperature remains above the critical threshold of 40.5°C. Although cold-water immersion (CWI) is the gold standard of treatment when cooling a patient with EHS, more recent alternative cooling techniques have been examined for use in settings where CWI may not be feasible (ie, remote locations). Clinical Question: Do alternative cooling methods have effective core body temperature cooling rates for hyperthermia compared with previously established CWI cooling rates? Summary of Key Findings: The authors searched for studies using alternative cooling methods to cool hyperthermic individuals. To be included, the studies needed a PEDro score ≥6 and a level of evidence ≥2. They found 9 studies related to our focused clinical question; of these, 5 studies met the inclusion criteria. The cooling rates for hand cooling, cold-water shower, and ice-sheet cooling were 0.03°C/min, 0.08°C/min, and 0.06°C/min, respectively, whereas the tarp-assisted cooling with oscillation (TACO) method was the only method that had an acceptable cooling rate (range 0.14-0.17°C/min). Clinical Bottom Line: When treating EHS, if CWI is not available, the tarp-assisted cooling method may be a reasonable alternative. Clinicians should not use cold shower, hand cooling, or ice-sheet cooling if better cooling methods are available. Clinicians should always use CWI when available. Strength of Recommendation: Five level 2 studies with PEDro scores ≥6 suggest the TACO method is the only alternative cooling method that decreases core body temperature at a similar, though slower, rate of CWI. Hand cooling, cold showering, and ice-sheet cooling do not decrease core body temperature at an appropriate rate and should not be used in EHS situations if a modality with a better cooling rate is available.

"You probably can't feel as safe as normal women": Hispanic women's reactions to breast density notification.

BACKGROUND: Patient advocacy has led to state-level legislative mandates for the release of personal mammographic breast density information to women undergoing screening mammography. More research is needed to understand the impact of this information on women's perceptions and mammography screening behavior. METHODS: Semistructured interviews were conducted in English and Spanish with 24 self-identified Hispanic women who had undergone at least 1 mammogram since breast density notification was enacted in New York State. The women ranged in age from 43 to 63 years. Women were asked about their understanding and perceptions of the communication of New York State-mandated breast density information, and any actions they have taken or would take in response to this information. A content analysis of the qualitative data from the translated and transcribed interviews was conducted. RESULTS: The majority of participants had no prior knowledge of breast density and expressed confusion and apprehension regarding the meaning of dense breasts when presented with the notification information. Many participants understood having dense breasts to be a serious and abnormal condition, and reported feelings of worry and vulnerability. Participants mostly expressed a strong interest in learning about breast density and obtaining additional and more frequent breast cancer screening tests. These behavioral intentions were consistent with participants' overall favorable view of breast cancer screening and a belief that their faith, as well as regular screening, can help to protect them from breast cancer morbidity and mortality. CONCLUSIONS: Hispanic women conveyed proactive breast cancer screening intentions in response to breast density notification, despite inadequate comprehension of this information and negative emotional responses.

Need for Innovation in Public Health Research.

The recent conference Turning the Tide: A New Generation of Public Health Interventions highlighted the need to utilize innovative and emergent methodologies to confront increasingly complex public health challenges. In this commentary, we discuss three dominant themes from the conference: addressing multiple levels of causality in reducing health problems; technology-based methodologies to enhance health promotion; and improving translation and sustainment of effective health promotion programs. The subsequent articles, included in this supplement issue of AJPH, provide compelling examples and arguments supporting these progressive approaches to public health promotion. We recommend that public health researchers draw inspiration from these examples and embrace interdisciplinary, innovative methods within their future work.

Mixed-methods evaluation of mental healthcare integration into tuberculosis and maternal-child healthcare services of four South African districts.

BACKGROUND: The South African National Mental Health Policy Framework and Strategic Plan 2013-2020 was adopted to address the country's substantial burden and inadequate treatment of mental illness. It outlines measures toward the goal of full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, we conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of four districts in South Africa. METHODS: Forty clinics (ten per district) were purposively selected to represent both urban and rural locations. District-level program managers (DPMs) for mental health, tuberculosis, and maternal-child healthcare were qualitatively interviewed about district policy and procedures for management of mental illness and challenges in integrating mental health services into primary care. Clinic nurses and mental health practitioners (MHPs) completed a quantitative questionnaire to assess their engagement with stepped care for patients with mental illness. Qualitative and quantitative data were collected concurrently and compared to triangulate progress in implementation of integrated services. RESULTS: A total of 59 nurses and 17 MHPs completed questionnaires, and nine DPMs were interviewed (total n = 85). DPMs indicated that nurses should screen for mental illness at every patient visit, although only 43 (73%) nurses reported conducting universal screening and 26 (44%) reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialized care. However, only 7 (41%) MHPs indicated that they diagnose mental illness and 14 (82%) offer any treatment for mental illness. Addressing challenges to current integration efforts, DPMs highlighted 1) insufficient funding and material resources, 2) poor coordination at the district administrative level, and 3) low mental health awareness in district administration and the general population. CONCLUSIONS: Though some progress has been made toward integration of mental health services into primary care settings, there is a substantial lack of training and clarity of roles for nurses and MHPs. To enhance implementation, increased efforts must be directed toward improving district-level administrative coordination, mental health awareness, and financial and material resources.

The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care.

There is strong interest in implementation science to address the gap between research and practice in public health. Research on the sustainability of evidence-based interventions has been growing rapidly. Sustainability has been defined as the continued use of program components at sufficient intensity for the sustained achievement of desirable program goals and population outcomes. This understudied area has been identified as one of the most significant translational research problems. Adding to this challenge is uncertainty regarding the extent to which intervention adaptation and evolution are necessary to address the needs of populations that differ from those in which interventions were originally tested or implemented. This review critically examines and discusses conceptual and methodological issues in studying sustainability, summarizes the multilevel factors that have been found to influence the sustainability of interventions in a range of public health and health care settings, and highlights key areas for future research.