sions and four targeted family sessions. During the parent group sessions, parents discuss methods of prevention and how to communicate with their children. The information gathered in these group sessions is discussed in the family sessions. The program is highly participatory, said Estrada, and parents often find solutions to their problems among themselves. However, even though the program has been successful, like many evidence-based programs, it has not been widely disseminated.

In an effort to increase dissemination of the intervention, Estrada said, the Familias Unidas team created an online version of the intervention, eHealth Familias Unidas, using four different elements. The first element includes a parent group session via video, in which parents watch other parents have discussions about how to talk to their adolescents about difficult topics such as substance use and sexual behavior. Second, Estrada continued, the research team created a telenovela series with eight episodes that directly map on to the content of the parent video sessions. Third, the research team paired the video sessions with interactive exercises asking parents key questions. Estrada explained that the last component uses video-conferencing software to deliver virtual family sessions, which are the same as the family sessions conducted as part of the in-person intervention.

Estrada said feedback from clinic personnel, facilitators, and parents showed them how important it was to understand the relevance and effectiveness of the intervention. Feedback from clinic personnel highlighted the importance of minimizing clinic disruptions, providing an administrative assistant to sort through logistics, and having technical and clinical support. While the evaluation studies are still ongoing, Estrada shared preliminary results that show direct effects on past-90-day drug use from baseline to 24 months post baseline. There have also been positive parenting and parental involvement findings from baseline to post-intervention. Furthermore, Estrada reported, 63 percent of parents completed all of the sessions, while only about 16 percent did not participate in any of them.

The research team is working to apply their findings to an ongoing trial. Early on, they noticed that many families see primary care as a less stigmatizing setting to receive services, Estrada explained, and many families see doctors as trusted sources of information. The research team listens to the clinic personnel and integrates the feedback to make the program more likely to be sustained over time. In conclusion, Estrada said they are just beginning a Type 1 effectiveness implementation hybrid trial. This allows them to test the intervention randomizing time to look at sustainment as a primary outcome, which will help them understand whether the clinic is able to continue offering the program after the research team leaves.

retention. Participation in the intervention reduced risk of initiating use of a new substance by 37 percent and reduced risk of drinking by 26 percent. Additionally, the results showed decreased rates of reported anxiety.

In early childhood prevention efforts, Shaw described another sample of more than 700 families enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) who were randomly assigned to the FCU. This study (Galán et al., in press) demonstrated how intervening for children as young as two can lead to decreased substance use in adolescence by reducing lifetime risk factors and increasing lifetime protective factors.

Shaw also commented on genetic risk factors related to substance abuse. While there is a genetic component, his team conducted a study in which genetic risk that led to substance use in adolescence in the control group was attenuated in the intervention group for families randomly assigned to the FCU (Elam et al., 2022). The genetic risk can be thought of as malleable, he concluded.

Finally, Shaw shared results from the same WIC-based study looking at intergenerational trauma, considering children of mothers who experienced emotional, physical, and sexual trauma in their lives. For the control group, children of mothers (and mothers themselves) with trauma had higher rates of marijuana use than children of mothers who did not experience trauma (see Figure 3-1). In the group that participated in the FCU, children of mothers (and mothers themselves) who experienced these three types of maltreatment actually had lower rates of marijuana use than their peers.

(Petras et al., 2021). Secondly, she continued, there needs to be more effective communication and engagement with families. Moving forward, the first action should be centered on communicating to different audiences, she said. This can include articulating the economic benefits of prevention, as well as the investment in life potential. Human beings are resources more important than money, she continued. There is also an opportunity to develop more equitable models and to include families in prevention programs.

Differing Infrastructures

Miller called attention to the infrastructure needed to support the implementation of prevention strategies. Schools and health care settings provide great opportunities because of their easy access to the targeted age group, she said. They also represent existing infrastructures that have already established relationships with families. However, Miller noted, there are also barriers in these settings, such as the workforce not having the bandwidth to do more work and lack of engagement in school systems for some families. Furthermore, she added, schools may have difficulty reaching parents and caregivers, which can impede prevention efforts.

In the face of these challenges, Miller proposed more online delivery, noting the mounting evidence of its success, especially for primary prevention. Benefits include interactive content, low-cost delivery, and the ability for families to engage in self-directed delivery from their homes (Byrnes et al., 2019). Online delivery of prevention interventions can also be more easily updated with new information and current issues, she added. However, this avenue is not without challenges, as it requires funding to maintain the virtual components, requires families to have access to stable internet and technology, and requires funding for maintaining the websites that deliver interventions (Wang-Schweig et al., 2019). Miller suggested there are also opportunities to increase uptake of interventions through other community organizations, including faith-based organizations, community coalitions, and neighborhood hubs like barbershops or salons.

Internal Organizational Barriers and Facilitators

Even when an organization is well established and has a willing workforce, it may not be ready to implement a prevention intervention, said Miller. Additional organizational characteristics are needed to facilitate implementation, including organizational readiness (Shea et al., 2014), leadership for developing an implementation plan and supporting employee efforts (Aarons et al., 2015), and a climate of acceptance around how interventions are implemented (Ehrhart et al., 2014). Structural barriers

within organizations can also affect the implementation of family-based interventions, Miller added, including a lack of resources, a need for training on prevention approaches and outcome measurement, and disparity in access. Many communities do not have sufficient resources to provide effective prevention of adolescent substance use, she said. To better prepare for implementation, Miller noted, organizations should work with implementation science experts, invest in training in both the program and family engagement techniques, and engage in collaborative work and knowledge sharing with other community organizations and resources.

Laws and Policies

Lastly, Miller reviewed the barriers to and facilitators for laws and policies that support prevention interventions. For example, she said, evidence suggests that policies implementing higher alcohol taxes decrease adult alcohol consumption, which indirectly decreases youth drinking as well (Xuan et al., 2013).

However, Miller explained, there may also be unintended consequences of certain policies, as has been seen with social host laws, designed to discourage adults from hosting private parties with alcohol for teens. This can lead to teens having parties in less safe environments, such as local parks and open spaces. Miller commented that, instead of addressing the root problem, these laws just move the problem to a different setting. Finally, she added, passing a law does not necessarily mean it will be enforced. Studies have revealed that targeting adults who provide youth with alcohol or drugs requires resources, training, and buy-in from law enforcement (Jones-Webb et al., 2015).

Miller highlighted Mothers Against Drunk Driving as a successful example of efforts to change drinking and driving laws, which resulted in more legal enforcement, more serious legal and financial consequences, and more treatment approaches for drinking drivers with alcohol diagnoses. This effort, she said, represents a bottom-up or public demand for change rather than a top-down approach to create effective policies for addressing problems in communities.

Discussion Session with Panelists and Workshop Attendees

Initial questions from workshop attendees focused on how to shift the conversation from the opioid crisis to maintain a focus on prevention, as well as how to address prevention from a multiple substance standpoint. Miller expressed that part of the problem with shifting the conversation is that the health care system is fragmented, and so prevention and treatment often are not considered together when addressing substance use. Shaw

added that there is a need for systems of care at each developmental phase based on known challenges and available data. He noted community coalitions can also help sustain momentum and advance efforts when government support may wane. Regarding the use of multiple substances, Estrada noted that there are common underlying risk behaviors among youth, and that addressing those and examining the common protective factors could be an opportunity to move away from the single drug approach to prevention.

Another participant wanted to better understand why some families engage with interventions and some do not. Estrada replied that when looking at predictors of engagement for their intervention, they found that families with youth at higher risk are more likely to engage, as are parents with low social support. Regarding the FCU, Shaw answered that in many of their settings, the families are already at a health care appointment and so were waiting anyway. It was easy to convince them to engage in a 30-minute session. He added that they are seeing strong engagement rates with their online and remote versions as well.

Related to the importance of infrastructure, a workshop attendee asked if there is available information on where specific interventions are being implemented. Miller commented a central repository that inventories all of the evidence-based interventions could be useful to communities, but she did not know if one exists.

BARRIERS TO AND OPPORTUNITIES FOR WIDESPREAD SCALE-UP

While many programs have been successfully implemented in individual sites or systems, broadening their impact comes with its own challenges. This section highlights family-focused prevention in integrated care systems, challenges to more universal programs, and general barriers to widespread scale-up of these types of programs.

Parent-Focused Prevention in Integrated Care Systems

Jordan Braciszewski, associate research scientist and clinical psychologist at Henry Ford Health, presented his work on introducing a parent-focused prevention program into three integrated health care systems across the country, including Kaiser Permanente Northern California, Kaiser Permanente Colorado, and Henry Ford Health. He said Henry Ford Health, one of the largest integrated health systems in Michigan, is unique because they have embedded health researchers in most areas of care, enabling teams to be nimbler during implementation and delivery of programs since they are already working together.

health outcomes reported (Smith et al., 2020). None of the 40 programs reported substance use outcomes. Thus, Smith concluded, there is a need for research on implementation strategies for supporting the adoption and sustained delivery of parenting programs in primary care.

From both the scientific literature and his own experience, Smith noted four key implementation challenges: staff and workforce; time and space within primary care; funding issues; and framing of parenting-based prevention services. He reiterated earlier comments on issues of uneven supply and demand within the workforce, noting that most systems, especially those that are under-resourced, have very few behavioral health staff. Competing priorities can also make it difficult for patients seeking preventive services to access the staff they need, he added, especially when the staff are in short supply, because of the need to address more emergent mental health concerns (e.g., serious mental illness, suicidality). Even specialized behavioral health staff often lack adequate training in clinical psychology and may not be trained in specific skills for working with adolescents, Smith said, including the types of preventive and parenting skills that are the focus of this workshop. To address this in part, his team trains pediatric clinicians, nurses, and medical assistants.

Time and space are often in short supply with many of their partnering clinics, so Smith offers a different type of service delivery model. He described a recent trial comparing integrated/collocated care delivery models, both of which took place within FQHCs, with a referral-based model that refers families to a team providing a parenting intervention outside of the primary care system (Smith, Berkel et al., 2021). Within six months, they found the integrated/collocated care model would not be effective and was not sustainable. He said few families were referred, and those who were barely received services. While they had trained seven providers in these FQHCs, they just did not have the time to deliver the parenting program. Instead, Smith’s research team shifted to a full referral-based model for all FQHCs and other primary care practices and organizations. The referral-based model addressed the issue of lack of space to provide services (Berkel et al., 2021). In a second study with the same referral-based delivery strategy, Smith said, implementation moved from primarily home visiting to a fully telehealth model due to the COVID-19 pandemic, which also addresses the space limitations of the built primary care setting.

Economics drives much of the decision-making in implementation science and health care, Smith commented, and he called for a value proposition for preventing substance use. There are multiple perspectives to consider, such as cost-benefit analysis, cost effectiveness, or opportunity cost. Rather than looking at risk assessment and forecasting cost for the next year, which is not appropriate for a prevention program, Smith called for looking over several years to look at future costs and how those could

be saved (see Figure 3-2). Current alternative payment models may not provide adequate incentives for the transformation necessary to address those determinants of health care cost that lie outside current clinic workflows, he noted.

While there is often tension when moving interventions into real-world systems, Smith emphasized the importance of knowing that adaptation is expected and necessary, and implementing teams need to prepare for it such that adaptations are fidelity-consistent to the program (Smith et al., 2018). While this typically means the intervention shifts to fit the system, he said, there are also opportunities for the system to accommodate the intervention as well. He shared the idea of designing interventions from the outset to align with the end user’s needs, resources, capacities, and desires, which is called designing for dissemination and sustainability (Kwan et al., 2022). Finally, he concluded by emphasizing the importance of equitable implementation and taking into account such factors as the history of racial discrimination and inequitable access to health care (Smith, Davis et al., 2021).

Barriers and Opportunities in Health Care Settings

The family environment is a critical context for child health and development, said Pamela A. Matson, assistant professor of pediatrics at Johns Hopkins University School of Medicine. A core tenet of her work is understanding that promoting health for the parent also promotes health for the child and the entire family unit. She presented data from the Substance Abuse and Mental Health Services Administration (SAMHSA) showing that from 2009–2014 as many as 8.7 million youth were at home with at least one parent with an alcohol or illicit drug disorder. Household substance

use disorder is considered an adverse childhood experience (Merrick et al., 2018). It also poses a more direct risk for young children, Matson said, with research showing that young children of parents with alcohol use disorders have higher health care utilization rates and increased risk of a variety of medical conditions (Ray et al., 2007).

As other speakers mentioned, Matson commented on the multiple barriers to screening during pediatric visits, including provider concerns about parent acceptability of screening. Matson and her team conducted a study in Baltimore to evaluate whether parents thought it was appropriate for a pediatrician to ask these questions. Overwhelmingly, parents responded that it was appropriate, and they thought pediatricians should ask such questions (Matson et al., 2022). Matson explained the results did not differ between parents who reported that they did have concerning substance use in the home and those who did not.

To implement screening on a widespread scale, Matson called for a multilevel approach. First, she said, pediatric providers have a responsibility to screen their patients and be aware of household substance use. However, pediatric providers are not expected to diagnose, manage, or treat substance use disorders in parents or caretakers. Pediatric residency training should focus on increasing comfort with and use of screening tools for household substance use, she said. Matson also suggested developing competencies in universal prevention programs, specifically increasing adoption of the evidence-based Screening, Brief Intervention, and Referral to Treatment.

Echoing previous speakers, Matson noted that time constraints are a critical issue for many providers. She suggested this can be partially addressed by optimizing screening into the workflow of primary care settings and incorporating standardized screening instruments into the medical records system, thus making it accessible and easier for providers to use. She also reiterated that a paradigm shift is needed to move pediatrics upstream, from a model of pathology and disease to a model focused on leveraging a range of prevention activities in primary care settings (see Box 3-1).

Finally, keeping in mind the multilevel approach, Matson advocated for policies and programs to support workforce development and sustainability. For example, she suggested a program similar to the National Institutes of Health loan forgiveness program for people who commit to pediatric and health disparities research. She suggested SAMHSA could establish a similar program for social workers or other professionals to incentivize greater participation in primary prevention programs. Noting that recommendations from the U.S. Preventive Services Task Force (USPSTF) would go a long way in supporting widespread scale-up of these types of efforts, Matson said more research is needed to make that feasible.

tion study. He asked about other study designs or intervention trials that could generate the evidence needed without being duplicates of existing programs. Smith acknowledged this challenge, saying there is some push-back because some family-focused interventions have not been tested in the pediatric primary care system, even though they have been successful in homes, schools, and online. He suggested the cumulative trial proposed by Hendricks Brown as a potential novel research design, in which as soon as there is evidence beyond reasonable doubt, you shift into replication within the same grant period. However, Smith said, they have pitched it a few times, but reviewers are hesitant and funders require more insight on what the second phase might look like.

Adding to earlier comments about supporting the workforce, Vincent Guilamo-Ramos, Duke University School of Nursing, highlighted the fact that most health promotion and wellness is delivered by the more than four million nurses in the United States. Comparatively, there are roughly 35,000 pediatricians in the country. He called for broadening the focus to leverage the entire health care team. Braciszewski agreed, and said to implement the GGC program widely they need to enlist nurses, medical assistants, and other support staff.