Reframing Substance Misuse Prevention: a RE-AIM Analysis of Federal Infrastructure and Future Directions.

Cardiometabolic health problems, including type 2 diabetes (T2D) and cardiovascular diseases (CVD), are serious public health issues facing youth in the U.S. (Perng et al., ). Rising rates of T2D and CVD in adolescence are largely attributable to obesity, a major driver of preventable chronic disease, and if current trends continue, by 2050, 1 in 3 U.S. adolescents will have obesity (GBD 2021 US Obesity Forecasting Collaborators, ). Marked disparities exist, with higher prevalence in adolescents who identify as people of color, prefer a language other than English, live on a low income, and/or live in rural communities (Katz et al., ; Ogden et al., ; Wild et al., ). T2D is manifesting earlier in the lifespan and with worse severity (Lawrence et al., ), contributing to accelerated disease progression, earlier mortality, reduced quality of life, and substantial economic burden for families and society (Nadeau et al., ). Interventions to prevent or slow disease progression in adolescence are needed. Standard-of-care for obesity involves intensive health behavior and lifestyle treatment (IHBLT), a family-inclusive, multi-component intervention (e.g., nutrition and physical activity) with at least 26 contact hours (O’Connor et al., ). IHBLT is effective in reducing adiposity and related cardiometabolic risk in adolescents (Savoye et al., ). However, access to IHBLT is limited, particularly in rural communities (Finn et al., ), and sustaining behavior change after the end of structured programming remains challenging (Li et al., ). Rural families face unique barriers, including limited availability of specialized providers and programs, long travel distances, and reduced access to safe/structured physical activity and healthy foods (Davis et al., ; Ko et al., ). Thus, even when IHBLT is available, systematic adaptation is likely necessary to support acceptability, feasibility, and long-term sustainment in rural contexts. Accounting for local context is critical when implementing IHBLT in rural communities. Growing evidence suggests that local adaptation improves recruitment, retention, and efficacy of evidence-based interventions for diverse populations (Thier et al., ). Planned adaptation, conducted in close collaboration with community members from the outset as part of a pre-implementation, information gathering phase, can support the effective translation of evidence-based interventions to rural contexts (Jolles et al., ). The Practical, Robust Implementation and Sustainability Model (PRISM) calls for researchers to consider perspectives and characteristics of the target population, characteristics of the external environment, and the implementation and sustainability infrastructure of a context (Feldstein & Glasgow, ; Fort et al., ). Enacting PRISM through an added layer of equity (Perez Jolles et al., ) includes consideration of these factors through the lens of historical and current structural drivers of inequity. This work requires participatory co-creation with a diverse set of “interest holders” (i.e., groups with an interest in the issue under discussion; Akl et al., ), in which they share their experience, skills, and knowledge. Approaching intervention design in this way can support alignment between the intervention and the context and, thus, lead to better outcomes in contexts with unique needs, like rural communities (Jolles et al., ).