Scaling up public health interventions

Abstract

The scale-up of effective or efficacious public health interventions to prevent chronic disease is important if population wide impacts are to be achieved. However, scale-up is complex and doesn’t happen as often as it should. This is despite growing interest in the area of research translation and scale-up by researchers and policy makers and a plethora of conceptual frameworks developed to guide the scale-up of efficacious interventions. The objectives of this thesis are to understand how scale-up may be facilitated within a research translation framework as well as in the real-world by understanding the key factors that contribute to facilitating scale-up. A key finding from this thesis is that scale-up in the real-world does not occur in a linear fashion and is often influenced by a range of factors including the political and/or strategic context, values of key actors as well as community needs and the availability of funding. Furthermore, decisions to scale-up are not only determined by the level of evidence available, but also through the convergence of the abovementioned factors into an opportunity for scale-up, ‘the scale-up window’. The opportunities to facilitate scale-up in this thesis include: cementing ‘scale-up’ as the end goal within a research translation framework which places the emphasis on scale-up equally alongside the other research translation activities; conducting research that promotes greater understanding of implementation and scale-up (through replication and scale-up studies) while reducing the traditional focus of smaller efficacy trials that are not conducive for scale-up; encouraging the uptake of pragmatic tools that provide guidance to those considering scale-up, through assessing the potential scalability of interventions considered for scale-up to expedite more informed decision making; and by comprehensively reflecting on and documenting scale-up experiences which contribute to capturing lessons for researchers and policy makers. Finally, the field of scale-up may benefit from greater clarity around the ‘roles’ within research and policy settings on scale-up, which would increase the accountability for scaling up interventions as well as greater delineation between the growing field of implementation science and scale-up.