The concept of scalability: increasing the scale and potential adoption of health promotion interventions into policy and practice

Abstract

Increased focus on prevention presents health promoters with new opportunities and challenges. In this context, the study of factors influencing policy-maker decisions to scale up health promotion interventions from small projects or controlled trials to wider state, national or international roll-out is increasingly important. This study aimed to: (i) examine the perspectives of senior researchers and policy-makers regarding concepts of 'scaling up' and 'scalability'; (ii) generate an agreed definition of 'scalability' and (iii) identify intervention and research design factors perceived to increase the potential for interventions to be implemented on a more widespread basis or 'scaled up'. A two-stage Delphi process with an expert panel of senior Australian public health intervention researchers (n = 7) and policy-makers (n = 7) and a review of relevant literature were conducted. Through this process 'scalability' was defined as: the ability of a health intervention shown to be efficacious on a small scale and or under controlled conditions to be expanded under real world conditions to reach a greater proportion of the eligible population, while retaining effectiveness. Results showed that in health promotion research insufficient attention is given to issues of effectiveness, reach and adoption; human, technical and organizational resources; costs; intervention delivery; contextual factors and appropriate evaluation approaches. If these issues were addressed in the funding, design and reporting of intervention research, it would advance the quality and usability of research for policy-makers and by doing so improve uptake and expansion of promising programs into practice.

A guide to scaling up population health interventions

“…1,4−7 Although a number of frameworks and guides exist 4,5,8 , they have not been informed by empirical examination of how scaling up decision making and processes occur in high-income countries. To fill this gap, the New South Wales (NSW) Ministry of Health developed Increasing the scale of population health interventions: a guide.…”

“…4 This reduction in effect is in part because of difficulties maintaining the dose and fidelity of the original intervention in real-world settings. It is rare for interventions to remain unchanged as they are scaled up, because of the need to adapt them to suit the local context and the organisational, financial and human resources available for scaling up.…”

“…In the health sector, scalability is "… the ability of a health intervention shown to be efficacious on a small scale and or under controlled conditions to be expanded under real-world conditions to reach a greater proportion of the eligible population, while retaining effectiveness". 4 Scaling up is "... deliberate efforts to increase the impact of successfully tested health interventions so as to benefit more people and to foster policy and program development on a lasting basis". 5 Scalability is the capacity of an individual intervention to be scaled up, while scaling up is a process of increasing the scale of a successfully tested health intervention.…”

What is needed for taking emergency obstetric and neonatal programmes to scale?

“…Scalability includes planning for an appropriate evaluation approach [11] able to show that the programme continues to have worth [5] and is sustainable. Firstly, the problem that leads to the need for EmONC is one of morbidity and mortality.…”

“…Interventions or innovations that are converted into a programme mostly start with a research phase where the intervention is tested in a research setting before being implemented in practice on a large scale [1,11,12]. After the pilot it is expected that the key features of the intervention or innovation would be replicated in the further expansion, as it is important not to lose the essential characteristics of the tested new practices [13].…”