What influences evidence-based treatment sustainment after implementation support ends? A mixed method study of the adolescent-community reinforcement approach.

backgroundLittle is known about clinician perspectives regarding the factors that support or hinder the long-term delivery (i.e., sustainment) of evidence-based treatments in community-based treatment settings.

methodsClinical staff from 82 community-based treatment organizations that received federal grant funding to support the delivery of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment for adolescent substance use, were asked to participate in interviews focused on understanding their perspectives about the sustainment of A-CRA. Qualitative themes were identified using inductive and deductive approaches. Then the themes were dichotomized (present/absent) so that quantitative comparisons could be made between staff from organizations that sustained and did not sustain delivery of A-CRA. Administrative data about each organization in relation to federal funding support and their primary focus was also examined to explore whether these characteristics were associated with A-CRA sustainment.

resultsStaff (n = 134) representing 78 organizations participated in the interviews. Staff from organizations that had received multiple federal grants to support the delivery of A-CRA and whose primary focus was substance use rather than other conditions (mental health or primary care) were more likely to report sustaining A-CRA. Staff from sustaining organizations were more likely to report positive grant experiences and success with maintaining both organizational and external support in comparison to staff from non-sustaining organizations. Staff from non-sustaining organizations were more likely to report barriers to sustaining A-CRA, including more challenges with intervention delivery, and lack of internal support and external funding.

conclusionsOur findings lend empirical support for implementation theories in that multiple factors appear to be associated with long-term delivery of an evidence-based treatment. Although A-CRA was generally perceived positively by staff from both organizations that sustained A-CRA and organizations that did not sustain A-CRA, inner setting factors (e.g., structural policies, leadership support and staff retention) along with outer setting factors (e.g., external funding support) were reported as key to A-CRA sustainment.