Program scale-up in Canada: Lessons learned from the national implementation of a healthy relationships program

Background. Despite the large number of evidence-based programs targeting key public health problems, the sustainable translation of these programs into practice remains elusive. This study reports on practitioner feedback related to bringing the Fourth R, a curriculum-based program focused on promoting healthy relationships among adolescents, to scale in six Canadian provinces and territories. Methods. Participants were twenty-one practitioners (71% female) who were involved in the national Fourth R scale-up over the past decade. Quantitative survey and qualitative semi-structured interview data were collected, focusing on barriers to and attributes of successful program scale-up. Interview data were analyzed using qualitative description methodology. Results. On average, participants had been involved with the Fourth R for seven years, and most were affiliated with a school board. Three broad themes related to successful program scale-up emerged from the survey and interview data: 1) the importance of program characteristics (e.g., ease of use); the importance of the system (e.g., ministry of education endorsement/recognition); and the importance of the strategy (e.g., framing implementation around existing legislation and provincial priorities). While implementation fidelity was discussed by a number of participants as important to successful scale-up, only 36% of implementing sites reported that their jurisdiction had an existing process to monitor fidelity. Conclusions. The findings from this study highlight key factors that impacted the national scale-up of a school-based healthy relationships program in Canada. Findings can be used by researchers and practitioners who disseminate public health programs, in order to ensure the greatest impact on the health of communities.