Commentary on “How might the ‘Icelandic model’ for preventing substance use among young people be developed and adapted for use in Scotland? Utilising the consolidated framework for implementation research in a qualitative exploratory study”

A core tenet of implementation science is to promote the uptake and adoption of evidence-based practices (EBPs), or to de-implement practices that are not evidence-based. An ongoing debate among applied and theoretical implementation scientists exists between prioritizing EBPs with a strong evidence base or focusing on practices that are ready for adoption or broader scaling but have more limited effectiveness data. One way to address this tension is to critically evaluate a chosen EBP and its evidence base prior to adoption. A key part of this evaluation is to describe the evidence that supports, or does not support, the EBP for the intended implementation setting, context, and population.

Carver et al, thoughtfully and intentionally describe how they assessed the environmental context that could support or hinder that implementation of a multi-faceted, complex, public health prevention intervention that only has a preliminary, but promising, evidence base in “How might the ‘Icelandic model’ for preventing substance use among young people be developed and adapted for use in Scotland? Utilising the consolidated framework for implementation research in a qualitative exploratory study.” The study team explores the potential for transferability and adaptation of the ‘Icelandic model’ (IM) as an overarching framework to guide substance abuse prevention activities for young people in Scotland. The IM uses a multi-pronged and multi-level approach that includes engaging families, community organizations, schools, and policy makers. While the positive impact in Iceland has been dramatic, questions remain about the IM’s generalizability to other cultures and countries.

Using the Consolidated Framework for Implementation Research (CFIR), the authors explored barriers and facilitators to implementing the IM in Scotland using semi-structured interviews with key stakeholders from national organizations, subject matter experts, families with lived experience, and local organizations tasked with prevention activities. The study team uncovered several facilitators to the adaptation and implementation of the IM in Scotland. Notably, researchers found that the existing evidence base, adaptability, and the design, quality, and packaging of certain related activities and services were likely to promote adoption. However, the inherent complexity of the IM model and related activities were perceived to be a challenge due to the coordination of local authority areas and relevant stakeholders. Stakeholders emphasized how existing infrastructure and programs could be adapted and expanded under a more coordinated, unified strategy. Identified barriers to implementation include the political climate, health and social welfare policies, and the lack of long-term funding in social welfare.

In the manuscript, the authors describe the existing evidence of IM effectiveness as an important facilitator to gaining support for implementation amongst stakeholders and acknowledge the limitations of existing effectiveness research on the IM. While the study was exploratory in nature, the authors described actionable next steps to promote implementation including pilot testing within an underserved region (a critical step to elucidating the mechanisms by which the IM is effective) and creating a multi-agency approach to guide strategic planning, adaptation, and implementation. By using CFIR for a qualitative exploratory analysis, the study team make a unique contribution that bridges the expertise of researchers, practitioners, and policy makers to inform effective implementation.

In sum, the manuscript contributes to ongoing debate on what threshold should be used to coin a program, practice, or framework of activities “evidenced based.” Carver et al’s study, and studies like it, represent an important opportunity for the field: to study the dynamic interplay of multi-pronged interventions that are complementary across the policy and community levels. As governments, enterprises, and social service agencies at the local and national level continue to innovate and develop efficacious approaches to primary prevention, implementation scientists will have an important role to ensure adaptation to novel contexts. By leveraging an appropriate implementation lens and rigorous stakeholder engagement, adaptation of both discrete interventions and multi-faceted primary prevention models can be achieved with attention to both preserving potentially effective core components and cautious modification to match the unique social, political, and economic environment they are being introduced within.

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