Commentary on “The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care.”

This paper addresses sustainability, which is a critical but still relatively understudied area in implementation science. This publication, along with two others that have been recently published in Implementation Science ^{1, 2} reinforce the fact that there is significant variability both in the way that sustainability is defined and in the approaches taken to ensure sustainability. Yet sustainability is a critical concern both for implementers responsible for bringing evidence-based practices into field locations and to donors funding these programs. This article is an exploration of the key research questions that still need to be answered and potential methods to address them. The first question is the need to define sustainability clearly and consistently, and there seems to be an emerging agreement that sustainability involves the continued use of program components and activities that produce benefits over a period of time. The second question is whether sustainability is an outcome or a process, and while commonly used implementation frameworks such as EPIS and RE-AIM treat it is as an outcome, the authors point out neither of these conceptualizations may be enough to recognize the non-linear and dynamic nature of sustainability in public health settings where evolution and replacement of interventions and programs may be as desirable as maintenance of what has already been put in place. This leads naturally to the third research question that focuses on the relationship between adaptation and sustainability. It is clear that adaptations are important to contextualize interventions to make them attractive to local settings, but there is need for further research on which adaptations are most effective in improving sustainability in which contexts and how these adaptations should be done. Finally, there is the need to develop appropriate research methods to study sustainability because the effects can be only be measured several years after the program implementation is complete, and complex changes can occur in this period. Mixed methods and non-linear approaches from disciplines such as systems science and network analysis are needed, as is the need to develop robust multi-dimensional measures of sustainability. The authors have also developed a useful framework called the Integrated Sustainability Framework to identify the factors affecting sustainability, and have provided a preliminary list of emerging factors affecting sustainability in a variety of settings. Taken together, the articulation of research questions, the list of factors and the framework described in the article provide both researchers and practitioners with a useful conceptualization of an important area of concern in implementation science.

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¹J. E. Moore, A. Mascarenhas, J. Bain and S. E. Straus. (2017). Developing a comprehensive definition of sustainability. Implementation Science, 12(1), 110

2Lennox L, Maher L, Reed J. Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare. Implementation Science : IS. 2018;13:27. doi:10.1186/s13012-017-0707-4.