A: As far as our national replication strategy, we've taken very seriously the idea that the organization at the very least needed to be highly hospitable and well-prepared to conduct this program, and the organization had to be well-positioned in the community to conduct the program well. We now think that it's also important to have broad and deep community support for the program as well to ensure sustainable funding.

A lot of these sustainability issues are ultimately political. Over the years, we have gradually developed a whole function that focuses on what we call site development, and we've expanded that from site to state development because we believe that you just can't throw seeds on concrete. You really need to make sure that key agency leaders are committed to evidence and to this particular program and that they understand deeply the requirements that their organization will need to meet in order to conduct the program well. We ask organizations to sign a contract with us where we outline in detail what the program will look like and the operational indicators to be in compliance with the standards that we've established, and we make certain that organizations know they need to raise the money for the program. That requires a level of effort on their part that means that we're going to screen out those who are less committed. We've been very intentional about that because we believe that especially at the beginning of these phases of national replication, we want success, and we know that the success depends in part upon organizational capacity and leadership.

A: We know that we need to make some adaptations. We know that there are some challenges that we have in front of us right now. The rates of program attrition are higher than we've seen in our trials, and I think that part of it is that there are certain types of programmatic mandates that public health agencies have that make it difficult for them to hang on to families as completely as we did in our trials. We can use the information from our web-based information system and work with sites that are doing well to use the better sites as teachers for those who are not doing as well.

A: We have not done active marketing partly because we were concerned that if we did too much marketing, the demand would exceed our capacity. As we've thought about how to grow the program well, we've been very cognizant of the challenges that would be created if the demand exceeded our capacity. We've wanted to take it slowly.

We know we have some issues we need to take care of as we try to move this thing forward, and eventually we're going to want to conduct trials of the program in community contexts outside our existing trials. We think we can help those sites do an even better job because we know where some of the vulnerabilities are, and frankly, we don't want to rush into testing the program in community contexts until we've had a chance to work through some of these quality improvement activities and get sites brought into alignment with what we know we can do with them.

A: It used to be that people would come to me and say, "I want to learn how to do this kind of research," and I would say, "You sure?"

The truth is there are lots of sleepless nights; there are lots of pressures; there are lots of worries about funding. You're not sure that things are really going to be held together. We enjoy a good reputation today, but when I began this work, I was really wet behind the ears and had no reputation, no university affiliation even at the time I began this. What sustained me — and I think may sustain other people — is a passion for what we're trying to accomplish. If you really view it in the long run and keep in mind what you're trying to accomplish and feel passionate about it, then it can be sustained. If you don't feel passionate about it, at least in my case, I would never have hung in there. Unless it engages you at a deep level, you can't hang in with this kind of thing.