Bringing Programs to Scale in US Public Systems

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Although there are a plethora of evidence-based interventions that have been shown to improve health, many of them have not been scaled up to have population level effects across regions, states or the entire United States. Why is this? What has been studied and what is known about how programs go to scale in US public health systems? The answers to these questions was the charge to the Society for Prevention Research (SPR) Mapping Advances in Prevention Science (MAPS) IV Translation Research Task Force, funded primarily by the National Institute on Drug Abuse of the National Institutes of Health.  The Task Force reviewed the literature about lessons learned about going to scale in the welfare, education, behavioral health, criminal justice and public health systems.  I participated as a public health expert in this effort by reviewing the literature on public health systems.

The biggest learning from our work is that there is little known about going to scale for evidence-based interventions – programs and policies – in public systems.  Although there are some theories in the implementation and dissemination research that have “sustainability” and “dissemination” as a final stage of a framework or model, very few studies of scaling-up—either prospectively or retrospectively—exist in the literature.  The public health literature in the international sphere had the few studies that do exist on scaling-up of programs.

From the literature review across the five public systems, the Task Force identified six factors that are associated with the scaling-up process: public awareness, skilled workforce, data and evaluation capacity, leadership, community engagement, and developer/funder capacity.  Very little money has been allocated for intervention research on going to scale and few journals publish articles on these types of studies. The need for future research on this process in all five public systems is evident. Implementation science and research needs to embrace new models and paradigms, such as community quality improvement in place of random control trials and local level monitoring data systems.

I summarize the recommendations for the next steps in the public health system to address this dearth of studies and framework for scaling up public health evidence-based interventions in a Brief Paper on the SPR website.  They include:

  • Develop a framework and methods for studying the scaling-up of programs and policies in the public health system,
  • Increase awareness about evidence-based solutions to improving health among the public, practitioners and policymakers,
  • Include prevention science about “scaling-up” in public health curricula, accreditation criteria, and public health competencies, and
  • Invest in the science of “scaling-up”.

The Institute for Community Health (ICH) has an opportunity to help close the gap in what is known about scaling up programs to have a population-level effect.  ICH staff expertise and skills can be used to design and conduct studies of scaling up at the local, state and regional levels.  Foundations, government agencies and other funders need to invest in studies that identify the key components of success in scaling up interventions so that population health and well-being can be improved.


Fagan, A.A., Bumbarger, B.K., Barth, R.P., Bradshaw, C.P., Cooper, B.R., Supplee,           L.H., & Walker, D.K.  (2019). Moving the needle on scaling-up evidence-based             interventions in U.S. public systems: Challenges and opportunities.  Prevention Science, 20, 1147-1168.

Walker, D.K. (2019). Taking Evidence-based Interventions to Scale in Public Health Systems. Brief Paper. Society for Prevention Research.

Deborah Klein Walker, EdD

Board Member