Although the public health community has developed many evidence-based practices to promote healthy behaviors, adoption of these practices has been haphazard (1,2). In response, the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) have called for more attention to dissemination of evidence-based practices and for research on how to increase dissemination effectiveness (3-5).

Several conceptual frameworks have been developed to organize the extensive literature on diffusion and dissemination of evidence-based practices. Particularly relevant for the dissemination of evidence-based health promotion practices are those of Greenhalgh et al (6) and Wandersman et al (7). Greenhalgh, focusing on system-level practices in large health care organizations, reviewed the literature on dissemination and diffusion and developed a conceptual framework to organize it. Wandersman focused more directly on health promotion practices that might be implemented in both small and large organizations; his interactive systems framework (ISF) highlights the roles of key actors in the dissemination process. Another recently developed framework that synthesizes several existing frameworks (including that of Greenhalgh) is the consolidated framework for implementation research (CFIR) (8). Finally, the RE-AIM framework, though developed for evaluation, is widely used to provide organizing principles for the dissemination of evidence-based practices (9).

These frameworks are useful for generating hypotheses for future research, but no practical framework exists for developing and testing dissemination approaches. Such a framework would serve as a guide to dissemination for community-based organizations and help researchers develop and test approaches to dissemination of evidence-based practices.

We describe a practical framework for dissemination developed at the University of Washington Health Promotion Research Center (HPRC), a Prevention Research Center funded by CDC to conduct research on community-based prevention and control of chronic diseases. To illustrate the framework, we use 2 dissemination approaches we have developed and tested and discuss practical roles researchers play in dissemination and dissemination research.

The evidence-based practices that can be disseminated using our proposed framework (Figure) include environmental changes, policies, programs, and systems. Examples of evidence-based practices include research-tested environmental changes (eg, increased availability of healthy food in schools and workplaces), policies (eg, employer insurance coverage of treatment for tobacco cessation), programs (eg, healthy-aging exercise programs, such as Matter of Balance [10] and Active for Life [11]), and systems change (eg, expanded hours for mammography clinics).

The HPRC framework acknowledges that practices can spread either passively or actively. The "diffusion" arrow illustrates that some evidence-based practices spread passively and are adopted without additional support or instigation from outside the user organization (12). The larger dissemination approach arrow shows that diffusion alone is often not an effective way of spreading evidence-based practices and that specific efforts are required to encourage widespread implementation. The framework focuses on the active dissemination process.

The HPRC framework has 3 main actors: researchers and disseminating organizations (Figure, left) and user organizations (Figure, right). Researchers seek to create new knowledge to aid dissemination of best practices. Disseminating organizations ("disseminators") use that knowledge to lead dissemination efforts. User organizations put best practices into place. Disseminators may be nonprofit organizations that market an evidence-based practice (eg, through licensing or sales of a branded health promotion program) or foundations or governmental agencies that fund user organizations to support adoption and researchers to evaluate implementation of evidence-based practices (eg, grant funding provided by the Administration on Aging to encourage adoption of evidence-based practices).

Researchers and disseminators build a mutually beneficial collaborative partnership. The partnership can be initiated by either party and, in our experience, is most effective when the research team and the disseminator are trying to reach the same user organizations and are willing to learn about each other's resources and goals. Building on this learning, both the researchers and the disseminator are better equipped to design and test dissemination approaches that fit the disseminator's goals and capacity. Researchers work closely with disseminators in refining and testing the dissemination approach to make it more suitable for user organizations. Although researchers can serve as disseminators, disseminators have at least 2 advantages in disseminating best practices: 1) they can focus on dissemination, rather than on research objectives and funding, and thus focus on the support systems needed to reach the scale necessary to make a difference at a population level; and 2) they may be closer in culture and values to user organizations than are researchers and thus better able to promote best practices and adapt them to local needs.

Successful dissemination of evidence-based practices in a user organization involves a cascade of steps (Figure). Steps include adoption, implementation, and maintenance. The cascade also acknowledges the fixed elements of the user organization — that is, the state of the organization before dissemination — and its readiness to support adoption, implementation, and maintenance, including the availability of human and financial resources. The terminology parallels the adoption, implementation, and maintenance steps in the RE-AIM framework (9). The output of this cascade is change in organizational practices and personal behaviors that result in improved health and other benefits (eg, increased productivity) for either the members of the organization (eg, its workers) or the consumers it serves.

Between the boxes showing the researchers and the disseminators on the left and the user organizations on the right is the bi-directional "linkages and learnings" arrow. This arrow highlights the need for understanding user organizations and all potential steps in the implementation process, from readiness factors through how to motivate adoption and facilitate implementation and maintenance. We believe these linkages and learnings should be informed by principles of social marketing, which focus on the needs and capabilities of user organizations. Applying these principles, the disseminator begins with a market analysis (13). This analysis assesses the potential benefits of the evidence-based practices — to both the user organization and to its members and consumers targeted for behavior change — and potential barriers to adoption (both organizational and individual). The analysis evaluates 5 key areas (13):

By conducting a full market analysis, the disseminator will be prepared to decide which segments of potential user organizations to target and how to best position the evidence-based practice(s) for these targeted segments (14). The process of segmentation can begin either at the organizational level (identifying unique groups of user organizations that are particularly well-equipped to adopt the practice) or at the individual level (identifying unique groups of individuals that the disseminator believes should adopt the behavior(s) that the practice promotes). In targeting, the disseminator identifies the specific segment(s) for which it wishes to develop a dissemination approach. Once the target is identified, the dissemination approach should be positioned to communicate the benefits of the promoted practices clearly and concisely, stressing the particular benefits that are expected to resonate with the target segment. At the level of the user organization, for example, positioning asks, What specific organizational needs will be met with this practice, more so than with other practices, and why?

In summary, the HPRC framework proposes that to disseminate evidence-based practices effectively, researchers must 1) collaborate with a disseminator and 2) work with user organizations to refine the practice and approach to dissemination, guided by the principles of social marketing.

In this section, we present 2 examples to illustrate the dissemination framework (Box 1). EnhanceFitness (EF) promotes physical activity among older adults, and American Cancer Society (ACS) Workplace Solutions (WPS) promotes the prevention of chronic disease among workers. In each example, we italicize key terms from Box 1.

The HPRC framework for dissemination and dissemination research builds on the literature and has been shaped by our successful experience in developing and disseminating chronic disease prevention practices. As the 2 examples show, we have worked with private organizations as national disseminators, using theory-based dissemination approaches, and have achieved nationwide reach of evidence-based practices. The Workplace Solutions package of evidence-based practices includes environmental changes, policies, programs, and systems changes, so we believe this framework is applicable to all of these areas and to the broad field of translational research (5,18).