Examining Evidence-based Intervention Sustainability and De-adoption in the Context of HIV Prevention

Graduation date: 2016Evidence-based interventions (EBIs), which demonstrate efficacy in research settings, are rarely sustained when implemented in public health organizations. Rather, EBIs are often de-adopted - potentially undermining the positive benefits of the EBIs for the communities that access them. The lack of sustainability is particularly troubling among public health organizations that provide HIV-related services given that many vulnerable, at-risk individuals rely on these services for prevention and care. Characterizing the relationships among the many factors theorized to influence EBI sustainability and subsequent population outcomes may be a critical step to improving our understanding of how EBIs are sustained. Furthermore, the potential impact of EBI de-adoption is relatively unexplored. Given that new EBIs will continue to emerge, this dissertation research contributes to a growing body of knowledge dedicated to understanding the end phases of EBI implementation - sustainability and de-adoption - for HIV prevention in local settings. To achieve this goal, a multi-stage study was conducted, the results of which are presented in two manuscripts. First, a mixed-methods case study of a community-based organization dedicated entirely to HIV prevention that implemented and de-adopted RESPECT, an HIV prevention EBI was conducted. This case study and other existing data were used to inform the construction of an agent-based model, an innovative simulation approach. The agent-based model was then used to examine the impact of human resources on EBI sustainability and population risk over time. The results from these analyses, presented in the first manuscript included in this dissertation, suggest that human resources are integral to EBI sustainability, and adequate human resources must be invested to sustain EBIs and maximize benefit for communities over time. Data from the case study were also used to examine the impact of de-adopting RESPECT in this agency. The results from these analyses, presented in the second manuscript included in this dissertation, demonstrate how de-adopting an EBI has consequences, many of which are negative, for individual staff, the agency, and the community. This work can be used to inform conceptual frameworks and methods informing the study of EBI sustainability and de-adoption. This work can also be used to make recommendations for HIV prevention policy and the promotion of EBIs in practice. A continued focus on sustainability and de-adoption is a crucial opportunity to improve EBI success to maximize the benefit of EBIs for communities