Behavioral Health Implementers' Perspectives on Facilitators and Barriers to Sustaining Evidence-Based Prevention...

The U.S. Department of Defense (DoD) requires the implementation of evidence-based behavioral health interventions (EBIs) to prevent harmful behaviors such as suicide, harassment, sexual assault, and partner and child abuse. However, EBI sustainment with fidelity over time is a tremendous challenge, and a failure to do so limits the potential impact of these EBIs. Although implementation science theories and empirical research have identified determinants of EBI sustainment in the civilian context, unique aspects of the military social ecology likely influence sustainment in this context. Building on our prior leader interviews, this study examines program implementers' perspectives on factors influencing military behavioral health EBI sustainment. The combined perspectives of leaders and implementers will inform a military-specific model for implementing and sustaining behavioral health EBIs that can then be empirically tested.

We conducted focus groups with 24 implementers representing 5 behavioral health EBIs currently implemented in the U.S. Military: 4 evidence-based sexual assault prevention programs and 1 longstanding, evidence-based suicide prevention program. We conducted a multi-step thematic analysis to identify supports and impediments to sustaining EBIs, organized by levels of the social ecology. Themes were organized using the Consolidated Framework for Implementation Research: outer setting (DoD, Congress, service, major command), inner setting (installation, service agency), characteristics of individuals (implementers, end users), and innovation characteristics. The New York University Institutional Review Board reviewed and approved the study (IRB-FY2020-4345), and the U.S. Army Medical Research and Development Command Human Research Protections Office provided concurrence.

Participants identified socioecological supports and impediments to sustaining EBIs in the military context and described how factors at the outer levels of the social ecology influence implementers' and end users' experiences. They noted the importance of (1) choosing EBIs that have been evaluated in a military context and have support from leaders in the outer and inner settings, and (2) implementation by an educated and trained workforce. Notably, aspects of military culture (e.g., hierarchical structure, frequent moves, mission focus, mandated participation) can both support and challenge the implementation of behavioral health EBIs.

Prevention implementers confirmed leadership-identified military-specific social-ecological factors influencing behavioral health EBI fidelity and sustainability, while providing unique, on-the-ground insights into implementer and end-user experiences. The study's results reinforce the need for implementation scientists to use a military-informed model to understand the determinants of sustained EBI implementation. Further evaluation of this model is warranted to document the relative contributions of these determinants and identify priorities for enhancements that can improve the sustainability of military behavioral health EBIs, ultimately improving the well-being of service members and supporting mission readiness.