A blueprint for a national prevention infrastructure: what the US National Academies propose

This article is based on the consensus study report of the National Academies of Sciences, Engineering, and Medicine (2025), “Blueprint for a National Prevention Infrastructure for Mental, Emotional, and Behavioral Disorders”. It sets out the report’s core messages and their implications for practitioners in prevention and health promotion, with a view to what a European country might take from a document written for the United States, and to the contribution that approaches such as Communities That Care (CTC) can make.

Introduction: the need for a strong prevention infrastructure, in Europe too?

The United States faces a growing crisis of mental health and substance use, with high human and economic costs, and marginalised groups are hit hardest. While treatment and rehabilitation are important responses, the prevention of mental, emotional and behavioural disorders – referred to here, for simplicity, as mental health and behavioural problems – often receives less attention and fewer resources. The National Academies’ report argues persuasively that many of these disorders are preventable, and that a more robust national prevention infrastructure is decisive for reducing risk factors and strengthening protective factors across the whole life course. European health and social systems differ from the American one, and from each other. The question is nonetheless worth asking: are the challenges and the solutions the report identifies relevant to a European country? This article outlines the core components of such an infrastructure and leaves the reader to hold them against their own national landscape.

The six pillars of a prevention infrastructure

Read as a whole, the report describes six pillars. The summary is ours; the substance is the report’s.

1. Evidence and policy: grounding in scientific knowledge; supportive laws, guidelines and programmes.
2. Workforce: a sufficient number of qualified, diverse and fairly paid prevention professionals.
3. Data and monitoring: systematic collection and use of data for needs assessment, planning, steering and evaluation, including small-area data.
4. Governance and partnerships: clear steering and accountability; effective coordination between levels of government and across sectors; strong partnerships.
5. Funding: adequate, sustainable and flexible funding models for prevention measures and structures.
6. Implementation and equity: effective transfer of knowledge into practice; reduction of inequalities and attention to vulnerable groups.

The pillars are interdependent and shape one another. Guiding principles such as health equity and implementation research run through all of them.

Main findings of the US report: building blocks for effective prevention

The report identifies several key areas that are indispensable for building an effective and sustainable prevention infrastructure. The findings were drawn from the American situation. After each, we note the question it puts to a European country.

1. A fragmented landscape and unused potential. The US prevention infrastructure is fragmented and unevenly developed. There are government agencies at every level, academic networks and national associations, yet the structures for preventing substance use are better developed than those for promoting mental health, and the focus often rests on children and adolescents alone. The report stresses that gaps should be closed and that existing systems – health care, public health, education – should be used as the foundation.
   The question for a European country: despite established structures, where does fragmentation persist between national, regional and local government, and between departments? How well are addiction prevention and the promotion of mental health coordinated with each other?
2. Evidence-based programmes and implementation science at the core. A solid evidence base exists for preventive interventions, especially for young target groups (for example the Nurse-Family Partnership and the Good Behavior Game). The main problem is transfer into practice. Implementation science – how “what works” actually reaches people – is singled out as decisive. Adaptation to context and participatory development are essential.
   The question for a European country: the research-practice gap is familiar everywhere. How can evaluated programmes be delivered at scale and with quality assurance? How can implementation research be strengthened and systematic adaptation encouraged?
3. The need for coordinated governance and partnerships. Steering in the United States is splintered. The report calls for clear governance structures, central coordination at the White House, stronger coordination within the federal health department, and a structural change at the federal agency for substance use and mental health to put the promotion of mental health on an equal footing with addiction prevention. Strong cross-sector partnerships are indispensable.
   The question for a European country: federal, regional or unitary, every European state divides responsibility for prevention between levels of government and between ministries. Where could stronger coordination lift synergies? How can existing partnerships be strengthened? The report’s call to include people with lived experience in steering bodies is an impulse worth taking up anywhere.
4. Underfunding and the need for sustainable funding models. Prevention in the United States is massively underfunded; the estimated federal spending of around 4.57 billion US dollars is inadequate. The report proposes budget increases and innovative funding mechanisms, such as flexibility within the public health-insurance programme for low-income households, earmarked taxes, and the community-benefit obligations of non-profit hospitals.
   The question for a European country: even where a statutory basis for prevention funding exists, is it sufficient, flexible and well targeted? Are the contributions of health insurers or the national health service adequate for structural prevention, and not only for individual programmes? How can municipal budgets for prevention be made permanent? Are earmarked levies, or the involvement of non-traditional funders, worth considering?

Communities That Care as a way of strengthening the infrastructure locally

The US report calls for structured, data-driven and community-oriented approaches to improving prevention. That is exactly where Communities That Care starts, and it is an approach with two decades of European experience behind it. CTC offers a framework that can address many of the challenges the report identifies:

• Structured governance and partnerships: CTC rests on building a local steering group and a community board that take responsibility for the prevention process. This corresponds to the call for clear local governance and strong partnerships.
• Data-based needs assessment and prioritisation: a core of CTC is the systematic collection and analysis of local data on risk and protective factors using a standardised youth survey. This allows the most pressing problems and points of leverage in a community to be identified on the basis of evidence, and closes the gap in local data that the report criticises.
• Selection of evidence-based programmes: on the basis of the data, the coalition selects prevention programmes with demonstrated effect that fit the priorities identified, using an evidence register. This promotes the use of measures shown to work, as the report demands, and helps the community find its way through the sheer number of programmes and clearing houses, a difficulty the report describes.
• Implementation support: CTC is itself an implementation strategy. Through structured processes, training and coaching it helps coalitions deliver the selected programmes successfully and sustainably. This addresses the implementation gap directly.
• Focus on the community level: CTC builds local capacity and fosters the community’s ownership of its own prevention work, a central element for sustainability and acceptance.

By providing a systematic, participatory and data-driven process for planning and delivering prevention, CTC can contribute substantially, in any European municipality, to building the more coherent, more effective and better targeted prevention infrastructure that the US report considers necessary.

Practical implications for practitioners in prevention and health promotion

The report offers valuable impulses for prevention practice wherever it is read:

• Strengthen implementation competence. The report underlines that it is not enough to have good programmes; they also have to arrive. For practitioners this means extending their own competence in implementation. How do I choose the right programme? How do I adapt it? How do I evaluate process and effect? Knowledge of implementation strategies is central, and training and exchange on it matter.
• Actively shape cross-sector partnerships. Prevention is a cross-cutting task. Building networks with early-years settings, schools, children’s services, doctors, health insurers or health services is decisive for lasting success. Practitioners should see themselves as networkers and actively initiate and moderate cooperation.
• Put health equity at the centre. The report warns against overlooking inequality. In every European country, people do not have equal chances of mental health. Prevention services must reach vulnerable groups deliberately, which requires culturally sensitive approaches, low-threshold access and participatory development.
• Use data and close data gaps. Prevention needs a solid basis of data. Practitioners should use the data available and point out where it is missing. The report calls for small-area, comparable data, a need that exists in many European municipalities too.
• Advocate for prevention. The structural underfunding and often low priority of prevention are felt in Europe as well. Practitioners have an important role as advocates. They can argue from evidence and press for better framework conditions.

The prevention implementation cycle

The report’s recommendations can be condensed into a cycle that is continuous, community-oriented and data-driven. Our rendering, after the report:

1. Needs and problem analysis: what is the problem? What data and information do we need?
2. Selection of the intervention: which evidence-based measure fits?
3. Stakeholder analysis: who has to be involved? Who are the partners?
4. Context analysis: what are the local barriers and enablers?
5. Planning and logic model: how do we proceed? What are the goals and resources?
6. Evaluation: is the programme being delivered as planned? Is it working?
7. Adaptation: do we need to change or adjust anything?
8. Consolidation and sustainability: how do we secure the success in the long term?

Conclusion: learning from the US blueprint

The US report is far more than an analysis of American conditions. It holds up a mirror to any national prevention system, and the structural challenges it shows – fragmentation, implementation gaps, funding questions and the need to take equity more seriously – will look familiar to readers in most European countries. Which of them apply, and how sharply, is for each reader to judge against their own system.

Strengthening the prevention infrastructure – through better coordination, a consistent orientation to evidence and implementation, funding that matches need, a qualified workforce and good data – is a permanent task everywhere. The report supplies valuable arguments and concrete starting points for how it can succeed. For practitioners in prevention and health promotion it is a call to reflect on their own role in the system, to raise implementation quality, to strengthen networks and to press for the necessary framework conditions. Approaches such as Communities That Care offer a promising, structured frame for taking on these challenges at municipal level. A robust, equitable and scientifically grounded prevention infrastructure is a decisive investment in the mental health of a population, in the United States and in Europe alike.