Moving Evidence to Action: A Strategy to Support the Implementation of Comprehensive Violence Prevention Efforts

Abstract

For public health agencies, the pragmatic need to bring together science and practice to affect public health outcomes manifests in the implementation of prevention strategies with the best available evidence. Knowledge translation makes scientific findings understandable to the knowledge user, often through synthesis of the best available evidence. Implementation science promotes the adoption and integration of evidence through prevention strategies implemented within various contexts. Working together, knowledge translation and implementation science can promote the uptake and advancement of scientific and practice-based evidence for strategies that will have the greatest impact across a variety of contexts. Violence Prevention in Practice (VPP) is an online resource designed to help practitioners select, adapt, implement, and evaluate multiple prevention strategies included in five technical packages developed by Centers for Disease Control’s Division of Violence Prevention. A technical package translates the best available evidence into a core set of prevention strategies intended to be broadly implemented. VPP supports communities in using the technical package strategies in combination, drawing on key implementation science principles. In this article, we explain the process for developing VPP and provide a framework that can be used to develop similar guidance in other health promotion areas. The framework explains how both general components, such as selection and adaptation, come together with strategy-specific implementation guidance. Distinct from typical planning models, VPP is not designed as a linear stepwise process, and it allows practitioners to use one or more components alone, as well as helps practitioners link across components as needed.

Keywords

implementation violence prevention knowledge translation

The need to bridge science and practice in public health is well established (Brownson & Jones, 2009; Saul et al., 2008; Wandersman et al., 2008). While many frameworks initially depicted this bridge as a linear pathway that flows one way from science to the field (Green, 2008; Rubio et al., 2010; Westfall et al., 2007), other models illustrate this pathway as iterative feedback loops, indicating that evidence develops from practice too (Graham et al., 2006; Green, 2008; Wilson et al., 2011). For public health agencies, the pragmatic need to bring together science and practice manifests in the implementation of prevention strategies with the best available evidence to affect public health outcomes (Frieden, 2014; Haegerich et al., 2016; Puddy & Wilkins, 2011). A public health approach includes developing prevention strategies that address risk and protective factors for health conditions and ensuring widespread adoption and uptake of these strategies (Dahlberg & Krug, 2002; Mercy et al., 1993). This requires distinct yet related translation functions that define what the best available evidence is for prevention and how to promote the uptake of these strategies. We use two key terms in this article, knowledge translation and implementation science, to distinguish the what and how, respectively, of moving prevention strategies into action and widespread use.

Knowledge translation employs strategies that make scientific findings understandable to the knowledge user (Graham et al., 2006; Grimshaw et al., 2012). In the health promotion context, it includes processes and products that synthesize and communicate research findings so that they can be used by practitioners. Implementation science is the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies into health services and public health settings (Nilsen, 2015). It focuses on how to deliver the best available knowledge, such as evidence-informed prevention strategies, to affect public health.

Applying Knowledge Translation and Implementation Science in Practice

Numerous frameworks describe translation domains and functions (Nilsen, 2015; Tabak et al., 2012). To inform our efforts, we used two major frameworks that are widely applied within public health (Wandersman et al., 2008; Wilson et al., 2011). The Knowledge to Action (K2A) Framework, developed by Centers for Disease Control and Prevention’s (CDC’s) Workgroup on Translation, explains that knowledge translation begins with the decision to translate, turning knowledge into products, and dissemination of products to intended end users (Wilson et al., 2011). The second part of this phase focuses on product end users and includes partner engagement, decision to adopt, and practice, which is where putting knowledge into action takes place.

The Interactive Systems Framework (ISF) was developed by CDC’s Division of Violence Prevention (DVP) to address the gap between research and practice (Flaspohler et al., 2012; Saul et al., 2008; Wandersman et al., 2008). The ISF characterizes three systems that support and structure translation functions. The Prevention Synthesis System supports distilling research and preparing knowledge for dissemination and implementation. In the public health context, it is the knowledge translation of what should be implemented based on the best available evidence. The Prevention Support System focuses on building capacity before and during implementation. It includes both general and innovation-specific capacities that help practitioners select strategies, as well as training and technical assistance that supports implementation. General capacities include skills, structures, and processes that help organizations implement prevention efforts overall. Innovation-specific capacities apply to implementing a specific strategy. The Prevention Delivery System covers the actual implementation in practice settings. Like the Prevention Support System, the Delivery System has general and innovation-specific components that help practitioners implement violence prevention strategies.

Knowledge Translation Through Technical Packages

In 2014, former CDC Director Thomas Frieden described six components of effective implementation in public health (Frieden, 2014). One key component is a “technical package” of prevention strategies with evidence of effectiveness. Technical packages are knowledge translation products because they synthesize the best available evidence on public health strategies for practitioner audiences. Strategies included in a technical package are assumed to work synergistically and are intended to be implemented together for the greatest public health impact (Frieden, 2014; Haegerich et al., 2016). CDC’s DVP published five technical packages from 2016 to 2017 on youth, intimate partner and sexual violence prevention, as well as child abuse and neglect and suicide prevention (CDC, 2018). The strategies are the preventive direction or actions to achieve the goal of preventing violence. The approaches are the specific ways to advance the strategy. These approaches can be accomplished through programs, policies, and practices, examples of which were included in the technical packages. For example, Create Protective Environments is a strategy in multiple technical packages. Improving Safety and Monitoring in Schools is one approach within this strategy. Establishing and Consistently Applying Workplace Policies is another approach within the same strategy.

Applying Implementation Science to Promote Technical Package Use

While the technical packages represent translation of the best available research evidence, DVP knew that practitioners needed guidance on how to implement strategies within different contexts. The packages describe what the strategies and approaches are, but they do not describe how they should be delivered, the essential elements that should be maintained when adapting approaches to new contexts, or considerations for selecting strategies that are a good fit for community needs and assets (Perkinson et al., 2017). Yet another consideration for DVP is that its programmatic cooperative agreements guide funded recipients, mostly state and local public health agencies, to focus their efforts on implementing community- and societal-level strategies described within its technical packages. Many strategies to implement policies, environmental changes, and practices do not have specific implementation guidance, per se, which can pose unique dissemination challenges. Their implementation is highly dependent on the specific context within which they are being implemented. They also require different types of capacities to support implementation than manualized programs (Brownson, Fielding, & Green, 2018), and they may focus on a “best process” for influencing systems and taking action versus a specific set of activities (Green, 2001). In this case, implementation examples that can help describe how communities have made an approach work in their context are particularly important.

Finally, there is a paucity of models or guidance focused on selecting and implementing a comprehensive set of prevention strategies versus a specific program, policy, or practice. Although there are frameworks used to promote implementation of multiple evidence-based interventions (Kim et al., 2015; Spoth et al., 2004), these generally focus on building a system for implementation of multiple evidence-based programs. DVP recognized the need to develop resources to support public health agencies to implement a combination of technical package approaches in their state and local contexts. To address this gap, the Division developed an online implementation resource called Violence Prevention in Practice (VPP).

Application of K2A and ISF Frameworks

DVP used the K2A Framework as a road map for its process and to inform major considerations at each step. In particular, DVP engaged end users throughout the process and defined steps that would help design and disseminate resources in a way that explicitly promotes the adoption of technical package strategies. K2A defines this process as its “Translation Phase.” The ISF is widely used in violence prevention to define capacity areas needed to support and deliver prevention strategies. The technical packages fit within the ISF’s Prevention Synthesis System because they distill evidence within the field to a core set of strategies. The team applied the ISF’s general and innovation-specific capacity concepts—described within the ISF’s Prevention Delivery and Support Systems—to the overall approach and design. Most of VPP is designed to promote general capacities for a comprehensive violence prevention plan because this type of guidance is lacking in the field. The team decided, however, that one component of VPP should focus on innovation-specific capacities needed for different types of strategies within the technical packages, described later.

Purpose

In this article, we describe VPP, an online resource designed to help practitioners, particularly state and local health departments, select, adapt, implement, and evaluate multiple public health prevention strategies included in DVP’s technical packages. We explain the process for developing VPP using a framework that includes both general and innovation-specific components. And, we explain how this project illustrates a bridge from knowledge translation of the best available research evidence to promoting the adoption and use of evidence in practice.

A Five-Step Process for Developing Implementation Guidance

DVP formed a development team led by staff in the Prevention Practice and Translation Branch, which included contractors, staff from the communications team, and DVP leadership. The authors of the five technical packages consulted on the development of approach-specific guidance. The development process described herein is illustrated in Figure 1.

Figure 1

Process for Developing Violence Prevention in Practice

Step 1: Identify Key Decisions for Design and Dissemination

To start, the project lead met with stakeholders including DVP leadership, policy, communications, and science offices to discuss key factors for designing and disseminating the guidance in a way that would promote widespread use of the technical packages within DVP initiatives. The team went through a process to identify the purpose and goals, define the key audiences, and determine the most appropriate format. Having these discussions early in the development process was critical to later decisions about design and dissemination.

Step 2: Determine Guiding Principles That Will Help With Decisions About Content and Design

DVP also identified principles to guide the development of VPP early in the process and others during development. These principles guided decisions throughout the development process.

Step 3: Develop Content

To develop content that would be most useful for the primary audience, DVP gathered input from potential end users. Through interviews with DVP-funded recipients, the team identified implementation challenges and needs, which informed topics to cover in the guidance. Drawing on the implementation science and violence prevention literature, topics were organized into seven key sections. DVP reached out to potential users throughout the development process to ensure the team was on the right path. The team also gathered feedback from program staff who provide technical assistance to DVP-funded recipients and are aware of the common challenges. The technical package authors provided input on the content of the approach-specific guidance.

Because there were so many topics covered, it was critical to focus on the key points of each of the seven sections. The team developed action steps for each section to help users focus on the “takeaways” for initiating action. In addition, the team designed the resource to easily accommodate additional content and tools over time.

Step 4: Disseminate Resource

A top priority for DVP was making sure that potential users were aware of VPP once it was released. Leveraging the expertise of team members with communication expertise, the team created a dissemination plan to ensure that DVP-funded recipients are aware of the resource and can identify ways that it could support their work. The team also worked closely with national partners to ensure that potential users who do not receive CDC funding are aware of the resource. The dissemination plan incorporated social media, webinars, emails, and conference presentations. The plan also included training for DVP staff to help recipients access VPP and use the resource as part of technical assistance.

Step 5: Evaluate Resource Use and Identify Areas for Improvement and Expansion

It was essential to track how state and local partners were using the site to improve the user experience and tailor content to meet the evolving needs of the field. Evaluation staff identified diverse ways to collect information from users, including website analytics, webinar polls, and pop-up surveys that minimize burden and do not require many resources. DVP has conducted more in-depth data collection methods such as formal key informant interviews and surveys of website users. User feedback is analyzed on an ongoing basis to inform usability enhancements and the addition of new content.

Developing Violence Prevention in Practice

Key Decisions for Design and Dissemination

Identify Purpose

DVP determined early on that VPP should provide action steps and tools to help users make decisions that were in the best interest of their specific community. VPP focuses on both general capacities, particularly related to a public health approach, as well as approach-specific capacities. The purpose of VPP is to help users select a mix of strategies to implement comprehensive violence prevention versus implementing only a single program, policy, or practice.

Define Audience

Through a series of facilitated discussions with Division staff, DVP determined that the primary end user should be state and local health departments and coalitions involved in planning comprehensive violence prevention initiatives. These organizations are the typical stakeholders that receive DVP program funding. While the technical packages identify partners from multiple sectors, health departments and coalitions often serve as conveners and drive the planning process for violence prevention in their contexts.

Determine Format

DVP provides an online platform for its trainings, tools, and resources called VetoViolence. To leverage this existing platform and promote easy links to resources on VetoViolence, DVP determined that VPP should use an online format. Utilizing an online format provided the most flexibility to build on or update the content over time as needed.

Guiding Principles for Development

The team identified several principles to guide the development of VPP early in the process and other principles were identified during development. These principles included stay action focused, identify common approaches across violence types, focus on strategic and comprehensive violence prevention, facilitate access to information in a nonlinear manner, leverage existing resources, and ensure accessibility and relatability. Table 1 provides definitions for each of the guiding principles.

Table 1

Guiding Principles for Developing Violence Prevention in Practice

Principle	Description
Stay action oriented	A focus on action-oriented guidance shaped elements from language to the design of tip sheets and the focus of some resources, such as how to organize and use data to select risk and protective factors.
Identify common approaches	The resource should highlight common elements across different violence topics. Rather than focusing on the differences between the five technical packages, the resource should identify where common action steps and approaches exist.
Focus on strategic comprehensive violence prevention	The resources should help users think strategically about comprehensive violence prevention. The goal of the resource is to help users look at the multiple components of violence prevention rather than focusing on one single “solution.” In addition, the resource should help users focus on the purpose/objectives of an approach before selecting a specific policy, practice, or program.
Facilitate access to information in a nonlinear manner	The content in the resource should not be presented as linear. DVP recognized that users may need to focus on different sections at different times depending on where they are in their own processes.
Leverage existing resources	The resource should leverage existing resources wherever possible. The goal is to distill key highlights of content with links to more information when needed.
Ensure accessibility and usability	The resource should be accessible and relevant. Users should be able to see their own work in the content and examples. In addition, there should be tools and resources that users can utilize. It should be easy to navigate to information as needed.

Note. DVP = Division of Violence Prevention.

Content and Structure

Table 2 describes the main components of VPP, focused on action steps that can be integrated within existing systems or planning structures. The content is organized around seven sections. Six of the sections (planning, partnerships, policy, implementation, adaptation, and evaluation) focus on what are considered general capacities within the Interactive Systems Framework. A seventh section (selecting strategies and approaches) also includes a focus on “innovation-specific” capacities related to specific approaches. Users can search for implementation considerations specific to each of the approaches in the Technical Packages. Resources within each section include downloadable tip sheets that elaborate on a specific topic, and downloadable fillable worksheets. Descriptions of each section are described and examples of the content in each of the seven sections are provided in Table 2.

Table 2

Examples of Content Related to General Capacity

Section	Examples of content
Section	Action steps	Tip sheet or tool	Stories	Link to external resources
Planning	Prioritize risk and protective factors	Community Resource Assessments Tip Sheet	Public health approach to prevent violence in communities that experience disproportionate rates of violence in Boston	VetoViolence Connecting the Dots Training
Partnerships	Identify partners and their roles	Sustaining Partnerships Tip Sheet	UP2USNow Child Abuse Prevention Coalition in rural Oregon	SAMHSA’s Collaboration in Action Site
Policy	Identify a role	Policy Selection Key Questions Download	Family-friendly workplace benefits employees in a large Florida company	CDC Office of the Associate Director for Policy
Selecting Strategies	Select a mix of strategies	Selection Discussion Guide Tip Sheet	Priority strategy criteria for First 5 LA in Los Angeles County	VetoViolence Understanding Evidence Resource
Adaptation	Identify the essential elements	Planning Green Light Adaptations Worksheet	Identification of evidence-informed strategies that fit with the culture of youth-serving agencies in Houston	Essential Elements to Select, Adapt, and Evaluate Violence Prevention Approaches
Implementation	Take steps to increase implementation success	Implementing Multiple Approaches Tip Sheet	The Alliance for Evidence-Based Family Strengthening Programs, to support local communities in the implementation of evidence-based parenting and family support programs in North Carolina	National Implementation Research Network
Evaluation	Select indicators and identify data sources	Indicator Selection Tools	New Jersey workgroup of sexual violence prevention coordinators creating and piloting process and outcome evaluation tools for bystander intervention and media literacy prevention strategies	National Center for Injury Prevention and Control’s Policy Evaluation Briefs

Note. SAMHSA = Substance Abuse and Mental Health Services Administration; CDC = Centers for Disease Control and Prevention.

The topic of health equity is integrated throughout the seven sections to highlight concrete ways users can integrate health equity into their work. A health equity icon helps users identify action steps to address inequities in their specific communities.

Planning

The planning section focuses on strategies for writing a comprehensive violence prevention plan including using data for action, development of a shared vision, and prioritization of risk and protective factors.

Partnerships

Preventing violence requires many partners—private sector, community-based organizations, and government agencies—that have different strengths and limitations. This section includes tips for communicating effectively with a diversity of stakeholders and shares examples of effective partnerships other communities have developed to help users understand the impact that effective partnerships can have in preventing violence.

Policy Efforts

This section describes the variety of specific activities within a policy effort that public health agencies can implement. Examples include clarifying and framing violence prevention in terms of its effect on population health, educating policymakers, taking specific actions to ensure the benefits of policies, and evaluating policy options to prevent violence. Many of the policy efforts included in the technical packages were not originally developed as “violence prevention” strategies per se (e.g., paid family leave), so the section also provides users with external resources and suggestions for partners who can assist in their work.

Strategy and Approach Selection

The strategies and approaches section guides users through a systematic process for identifying a mix of approaches that fit their community needs and resources. The section also includes a tool for users to search for approach summaries by violence type or overarching strategy. For each approach, VPP highlights key objectives, implementation considerations, potential partners, key outcomes, and links to additional resources. In addition, it provides high-level information about each of the examples described in the technical packages. To help users focus on comprehensive violence prevention, the resource highlights approaches that address multiple types of violence. Examples of the information included in several cross-cutting approach summaries are included in Table 3.

Table 3

Examples of Approach-Specific Content for Cross-Cutting Approaches

Approach	Examples of content
Approach	Key objectives	Implementation considerations	Sector engagement	Example outcomes	Example policies, practices, programs
Strengthen Household Financial Security	Reduce the impacts of poverty and financial stress	Understanding of potential gains and barriers of increasing access to specific types of assistance through the use of health impact and feasibility assessments	Government	Reductions in maternal depression and parental stress	Tax Credits (e.g., Earned Income Tax Credit; Child and Dependent Care Tax Credit; Child Tax Credit)
Reduce Exposure to Community-Level Risks	Improve neighborhood cohesion and social support	Data on rates of crime and violence, alcohol-involved interpersonal and self-directed violence, and violence-related injuries to identify local areas with greatest need	Business	Improvements in neighborhood cohesion and social connections	Alcohol Policies
Parenting Skill and Family Relationship Programs	Foster safe, stable, nurturing relationships and environments	Opportunities to practice and reinforce skills are an important feature of programs with demonstrated evidence of effectiveness	Education	Improvements in parent-child communication and interactions	Incredible Years—Parent
Treatment for Victims/Survivors	Mitigate the behavioral and health consequences of experiencing or witnessing violence	Programs are delivered by licensed and trained professionals (e.g., clinician, social worker, counselor) and administered in a one-on-one or group format	Health care	Reductions in symptoms of posttraumatic stress disorder	Trauma-Focused Cognitive Behavioral Therapy

Implementation and Adaptation

The Implementation and Adaptation sections work hand in hand. The Implementation section describes key considerations and action steps for implementing a comprehensive plan, as well as a summary of general implementation capacities that apply to multiple types of approaches. The Adaptation section provides a framework and process for estimating the essential elements or active ingredients of an approach, considerations for making adaptations that likely will not compromise outcomes, and evaluating adaptations to assess whether or not they enhance the adoption and use of specific approaches.

Evaluation

The Evaluation section focuses on developing an evaluation plan and identifying available data for tracking indicators. This section promotes the use of evaluation to track adaptations and other implementation measures and links to various evaluation resources, such as an online logic model builder and other tools.

Dissemination and Evaluation of Violence Prevention in Practice

Since its release in November 2018, DVP has made presentations to a number of different stakeholders in conferences, webinars, and trainings. The resource also has been promoted on DVP’s social media accounts including Facebook and twitter. Because the resource is electronic, DVP also created a postcard with information about the resource and how to access it that is distributed at conferences and recipient meetings. Most recently, DVP created a promotional video about VPP that will be widely shared.

Over the first 13 months, VPP had over 15,000 unique visitors. Interviews and surveys conducted with users show that they find the resource informative, easy to navigate, and relevant to their work. VPP was used to guide strategic planning, strengthen collaborative partnerships, streamline research on potential strategies, and build capacity of staff and partners. Users reported appreciating the focus on an intersectional approach to Violence Prevention. End-user feedback has informed enhancements related to usability (e.g., addition of a glossary, increasing interactivity of graphics) and several areas for future expansion (e.g., health equity, developing and sustaining partnerships, resources to use publicly available data for planning and evaluation).

Discussion

All of our public health scientific knowledge on prevention would be of little significance if we did not also effectively deliver what we know can make a difference in a way that can improve the lives and health of communities. As a federal agency tasked with funding states and communities to implement violence prevention programs, DVP sought to apply implementation science in a way that would best impart guidance to facilitate systems and population-level change. DVP developed a resource, VPP, to help practitioners in their everyday important programmatic work by pairing guidance on both what is needed and how to do it. The resource helps users weave together a comprehensive violence prevention plan by strategically selecting, planning, implementing, adapting, and evaluating approaches. This advances DVP’s goal of getting approaches with the best available evidence into wider use and ensuring that agency funding is directed toward actions with the greatest potential for population-level impact. Importantly, VPP balances research-based evidence with community needs by providing guidance on selecting approaches that are a good fit and making adaptations that are unlikely to compromise outcomes. The process of developing VPP, as well as the resource itself, can serve as a model for providing implementation guidance for other funding and technical assistance agencies regardless of public health topic. Because VPP was initially developed with funded recipients in mind, DVP plans to evaluate use and perceived usefulness among other practitioners to understand its value to the field and to identify potential improvements. Monitoring and evaluation, including web analytics and end-user reports will help ensure that VPP can evolve to meet the changing needs of practitioners. VPP’s web-based format helps provide flexibility to add, modify, and update content over time. As new research- and practice-based evidence become available, it can be easily integrated into VPP, ensuring timely updated guidance.

Yet another consideration for DVP is that its programmatic cooperative agreements guide funded recipients, mostly state and local public health agencies, to focus their efforts on implementing community- and societal-level strategies described within its technical packages. Many strategies to implement policies, environmental changes, and practices do not have specific implementation guidance per se, which can pose unique dissemination challenges. Their implementation is highly dependent on the specific context within which they are being implemented. They also require different types of capacities to support implementation than manualized programs (Brownson, Fielding, & Green, 2018), and may focus on a “best process” for influencing systems and taking action versus a specific set of activities (Green, 2001). In this case, implementation examples provided through VPP can help describe how communities have made an approach work in their context particularly important.

Implementation is complex. There are multiple theories and frameworks to explain implementation science and guide implementation (Brownson & Jones, 2009; Milat & Li, 2017; Nilsen, 2015; Tabak et al., 2012; Wandersman et al., 2008; Wilson et al., 2011). As Wandersman et al. (2008) point out, however, various prevention models provide little information about how to move from research to practice. And, while what we understand about effective prevention strategies continues to grow, the growth does not always correspond directly to an increase in the use of effective approaches. One framework, the ISF, addresses this gap by providing an examination of the processes involved in moving through prevention synthesis, delivery, and support systems. However, the ISF was developed specifically as a “heuristic” to help clarify processes. It does not address the broader context where implementation actually takes place (Wandersman et al., 2008). Addressing contextual factors that affect health agencies’ implementation was the genesis of the VPP and what others have pointed to as an often-overlooked component of bridging research and practice (Brownson, Fielding, & Green, 2018; Hanson et al., 2012; May et al., 2016; Nilsen & Bernhardsson, 2019). By applying the process we describe for developing VPP, public health funders may ensure that important ideas will not “sit on the shelf,” but will actually realize practice application (Brownson, Eyler, et al., 2018). The goal is to help close the research–practice gap by advancing both science- and practice-based evidence to prevent violence. We see this transpiring through continuous feedback loops as VPP is used in real-world settings (e.g., learning from adaptations, implementations, and evaluations in different contexts) and improved on as new science or circumstances emerge. Most recently, the COVID-19 pandemic has resulted in practitioners needing to adapt prevention strategies to reach individuals remotely and integrate new community concerns. Through VPP, DVP is supporting the implementation of prevention strategies that have potential to change entire communities and groups affected disproportionately by violence.

Footnotes

Authors’ Note:

We thank Linda Dahlberg who led the development of the technical packages in CDC’s Division of Violence Prevention and contributed greatly to the approach-specific components of Violence Prevention in Practice (VPP). We also thank the numerous individuals who reviewed VPP at various stages including communications, policy and science offices within the National Center for Injury Prevention & Control, as well as the leads for the technical packages who reviewed drafts of approach-specific guidance. We are grateful for the work of ChangeLab Solutions in supporting the development of VPP, especially Benita Tsao. We are particularly grateful for the many partners and funded recipients who provided input at different stages during the creation of VPP and who continue to provide feedback.

ORCID iD

Kimberley Freire

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