A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in health

Recognizing the need for better methods to accelerate adoption of effective health practices and programs, researchers and funding agencies have expanded work in implementation science and the related disciplines of improvement science[1] and health systems and delivery research[2]. Generally speaking, these fields aim to identify barriers and facilitators to the adoption and use of effective practices and programs, and develop, test, and refine strategies for bridging the research-to-practice gap[1, 3‐5].

To date, however, most implementation studies have been conducted in relatively small- to moderately-sized samples of institutions, delivery systems, agencies, and/or communities[6‐9]. Although studies in small samples provide useful insights regarding local barriers and facilitators to adoption, the relevance of these findings for efforts to achieve large-scale adoption (i.e., scale-up or spread) in hundreds or thousands of institutions or communities is limited. Numerous practice-based efforts to scale-up and spread evidence-based health programs have been documented (although primarily in developing countries), but this work often does not employ theory-based, rigorous scientific approaches for studying scale-up processes, and thus offers limited evidence and guidance for improving future scale-up efforts. The terms ‘scale-up’ and ‘spread’ lack accepted, universal definitions[3, 10‐16]; we use the terms interchangeably and define scale-up and spread as ‘deliberate efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis’ (p. viii)[17]. Others use the term ‘going to scale’ when at least 60% of the target population that could potentially benefit from the program receives it[18, 19]. Development and use of the terms scale-up and spread are noted elsewhere[10, 12, 20].

Although limited, research interest in scale-up and spread is increasing. Much of this work has been conceptual or descriptive: developing frameworks and models for scale-up and spread[11, 15, 17, 21‐26]; discussing key issues in scale-up and spread[10, 20]; and describing strategies for achieving scale-up and spread[13, 14, 27‐29]. Furthermore, much of this work is narrowly focused, occurring in silos delineated by country, care setting, and/or health domain. There are few opportunities for cross-fertilization of ideas among researchers, practitioners, and policymakers engaged in scale-up and spread activities, and relatively few funding opportunities for research or practice efforts.

Responding to these challenges and the need for expanded research, practice, and policy to ensure that effective programs achieve impact on health at the population level, we launched a multi-stakeholder initiative to increase awareness and to identify specific actions needed to expand scale-up activity in health. The initiative was envisioned and launched during an informal, 30-person working dinner meeting held in junction with a panel session at the 2^nd Annual National Institutes of Health Conference on the Science of Dissemination and Implementation (2009). The dinner attendees proposed a state-of-the-art/agenda-setting conference involving approximately 100 U.S. and international representatives from research, practice, and policy in healthcare and public health, which we conducted during July 2010. The conference generated specific recommendations for actions needed to facilitate enhanced interest and activity in scale-up. A follow-up activity was conducted during Fall 2011 to prioritize and operationalize the recommendations. This article describes the methods and findings from the conference and the follow-up prioritization activity.

The five major conference recommendations, their associated sub-recommendation ‘action items,’ and participant importance ratings are listed in Table2. Below, we describe each recommendation and its key sub-recommendations.

In sum, the initiative described herein brought together expert researchers, practitioners, and policymakers to identify and prioritize next steps for advancing the field in a way that sought to minimize isolated projects conducted within individual silos, capitalize on the depth of knowledge and expertise available, and stimulate future activity. As an extension of the initiative, the authors are launching several follow-up activities to pursue these recommendations, including development of working groups charged with tackling the identified priority recommendations and sub-recommendations, delineated by a focus on research-based activities (e.g., develop registry of scale-up/spread expert researchers and projects; develop list of specific research questions or goals that might be addressed through new funding programs) and practice-based activities (e.g., providing peer consultation on the design and execution of emerging scale-up/spread projects; creating a mechanism to easily exchange information and provide support to scale-up/spread practitioners). The recommendations and sub-recommendations described herein are meant to specify actions to advance research, practice, and policy in scale-up and spread in health, and galvanize interest and effort in this area that are commensurate to its need.