Eight factors that decide whether a CTC implementation succeeds

The hard part is the how

Communities That Care promises a community a proven way to prevent substance use, violence and other problem behaviour among its young people. As with most science-based approaches, the real difficulty lies not in the what but in the how. The principles of CTC are clearly defined. Whether they change anything is decided by the quality of the implementation.

That is not a platitude; it is one of the best-documented findings in the CTC literature. In the randomised trial that established the evidence for CTC, the twelve intervention communities received a package: training, technical assistance, a funded coordinator and money for programmes. They installed the system with high fidelity (Quinby et al., 2008), delivered thirteen tested programmes with high adherence to core components and required dosage (Fagan et al., 2008), and four years in were running more tested programmes and reaching more children and families than the control communities (Fagan et al., 2011). Twenty months after the study’s funding ended, eleven of the twelve coalitions were still working (Gloppen et al., 2012). How well a coalition functioned predicted whether its community adopted science-based prevention at all (Shapiro et al., 2015).

The most recent European evidence tells the same story from the other side. CTC-EFF, a study led by the Hannover Medical School, examined whether CTC changes a community’s prevention system within a few years. Its observation window fell entirely into the pandemic, and unlike the US trial it did not fund a coordinator in the participating communities. Under those conditions implementation made little progress and a system effect could not yet be shown (Röding et al., 2026). The authors explicitly do not read this as evidence against CTC, but as evidence of how much depends on the conditions of implementation. A meta-analysis of the same sites supports that reading: across twelve matched pairs of communities it found a positive overall effect on the adoption of evidence-based prevention (g = 0.57) together with wide variation between sites, of which implementation quality alone explained 40.5 % (von Holt et al., 2025; so far a conference abstract). That does not contradict the null result of the larger primary study; it explains it. Where implementation was good, something moved. Averaged across all communities, it did not.

This article sets out the eight factors that, on the current evidence, decide whether a CTC implementation succeeds or stalls, and ends with a self-check a coalition can work through on its own.

What the implementation research shows

Two bodies of research inform the factors below. The first is the implementation literature from the United States, above all the studies that accompanied the Community Youth Development Study and the earlier state-wide roll-out of CTC in Pennsylvania. The second is CTC-EFF, which between 2021 and 2023 examined 38 German CTC communities alongside comparison communities and produced the first substantial European data on implementation quality (Röding et al., 2023).

From the US work, four findings stand out. Coalitions that started with higher readiness and functioned well internally were perceived as more effective (Feinberg et al., 2004). The amount of technical assistance a board received was related to how well it functioned over time (Feinberg et al., 2008b). In Pennsylvania, 90 % of coalitions continued after their initial three-year funding period and about two thirds were still operating four years after that grant ended, many having attracted funding at or above the original level (Feinberg et al., 2008a). And in the trial itself, coalition capacity and coalition functioning, not the mere existence of a coalition, predicted community adoption of science-based prevention (Shapiro et al., 2015).

From CTC-EFF, two capacity dimensions show a marked association with outcomes. Communities with strong cross-sector cooperation in prevention had 26 times the statistical odds of implementing science-based prevention; communities with strong community power, understood as the ability to develop plans that match local need, had 19 times the odds (Birgel et al., 2025). Both estimates rest on 38 communities and are correspondingly imprecise; the confidence intervals were corrected in 2025 and are wider than first reported. They are associations in cross-sectional data, not demonstrated causal effects. The same caveat applies to a related finding: in communities with high community capacity for prevention, the statistical odds of adolescent alcohol use were about 3.5 times lower (Birgel et al., 2023).

Across the German sites, five factors had the largest bearing on implementation quality:

• fewer barriers to cooperation between local institutions,
• stronger support from local champions, the key people who lend the process their authority,
• higher community readiness,
• good external support through training and technical assistance,
• sufficient working hours for the CTC coordinator.

The eight factors at a glance

Drawing on this research and on practical experience of CTC work, eight success factors can be identified. The list and the self-check below follow the implementation recommendations that the Hannover research group derived from CTC-EFF (Walter et al., 2025).

Sufficient resources for coordination

CTC-EFF is unambiguous on this point: an adequately staffed coordination post is decisive. The data show that the capacity and competence of the coordinator have a direct positive bearing on avoiding conflict within the coalition and on the quality of implementation. That mirrors the US experience, where the trial funded a coordinator in every intervention community and where the coordinator’s role in organising the coalition’s work is described in detail in the implementation studies (Fagan et al., 2009a; Arthur et al., 2010).

One of the commonest problems in practice is under-staffing. Many communities try to run the process on less than half a post, and it has proved counterproductive. The coordinator is the central interface between the participants, organises the overall process and holds the threads of communication together. All of this takes time and continuous attention.

Several funding models have proved workable for the coordination post, depending on the statutory framework in your country:

• co-funding by health insurers or public-health funds where prevention legislation allows it,
• anchoring the post in an existing structure such as the public-health department or the youth services department,
• for small municipalities, support from the county or regional authority,
• combining sources: the municipal budget, project grants and foundation funding.

Wherever coordination was adequately resourced, implementation quality and prevention outcomes were markedly better. The Pennsylvania experience adds a longer view: coalitions that survived their initial grant did so in large part because they found follow-on funding at or above the original level (Feinberg et al., 2008a).

Broad participation in the local process

Almost half of the coalitions surveyed in CTC-EFF rated the involvement of different groups as insufficient. Participation was lowest among parents, leisure and sports providers, local media and volunteers, and it is precisely this diversity that long-term success depends on.

A typical pattern illustrates the point. In several communities the coordinators wanted to start with a small circle and enlarge the coalition only after the youth survey. The strategy proved a hindrance, because carrying out the survey well already required a broader network. The initial assumption, that further partners could be won only once the survey results were in, turned into its opposite: without broad participation it was harder to conduct the survey comprehensively in the first place. The US implementation literature reports the same lesson from the other direction, with a whole paper devoted to strategies for winning and keeping schools as partners when the first approach does not succeed (Fagan et al., 2009b).

A diverse community board brings decisive advantages:

• different professional perspectives on prevention,
• access to different target groups and settings,
• a wider range of resources and competences,
• higher legitimacy in the community,
• deeper anchoring of the prevention approach.

An effective way to win participants from different fields is to begin with personal conversations with key people in each of them, conversations that present the CTC approach and, more importantly, work out the potential benefit for that person’s own institution. That is how a coalition is built that from the outset spans schools, youth work, health, police, urban planning and parent representation.

Effective communication within the coalition

The quality of communication within the team emerged as a critical success factor. Around half of the German communities rated their current communication as insufficient, with negative consequences for team spirit, the frequency of conflict and, ultimately, the quality of implementation.

Successful communication in CTC communities has these features:

• a fixed meeting rhythm that people can plan around,
• clear roles and responsibilities within the team,
• transparent documentation of decisions and next steps,
• a mix of channels: in person, online and hybrid,
• a respectful culture that takes different perspectives seriously.

A hybrid model works particularly well: monthly meetings in person for strategic work, complemented by short online formats for updates and coordination in between. A shared digital workspace holding all relevant documents, minutes and materials supports transparency and makes it far easier for new members to find their feet.

Where to begin

Eight factors raise the obvious question of where to start. The research offers a clear orientation. The table below suggests which factors deserve priority at each stage of a CTC implementation.

A note on this ordering. It is an orientation, not a rule. Local circumstances may justify different emphases. What all eight factors have in common is that they should not be considered in isolation: they influence one another and have their greatest effect together.

A self-check for coalitions

The following criteria are meant to help a coalition place its own implementation systematically. They are designed to be worked through without outside help: go through the fifteen criteria in order and note, for each, the level that comes closest to your community’s situation. The assessment is your own, ideally made together in the coalition.

Resources and structural anchoring

1. The working time available for CTC coordination:
   • less than a quarter of a post
   • a quarter to under half
   • half to under three quarters
   • three quarters to under a full post
   • a full post or more
2. The funding of the coordination post is secured for:
   • less than one year
   • one to two years
   • three years
   • four to five years
   • more than five years
3. The coordinator has a budget of their own for CTC work:
   • no
   • yes, but limited
   • yes, sufficient

Participation and composition of the coalition

4. Our coalition includes representatives from this many different fields:
   • one or two fields
   • three or four
   • five
   • six or seven
   • eight or more
5. Parents and/or young people are involved in the CTC process:
   • not at all
   • occasionally
   • regularly, in an advisory role
   • actively contributing
   • as permanent members of the coalition
6. Local decision-makers support the CTC process: rate from 1 (not at all) to 5 (very strongly).

Communication and cooperation

7. The coalition meets:
   • irregularly, as needed
   • quarterly
   • monthly
   • every two to three weeks
   • weekly
8. Between meetings there is a structured exchange of information: rate from 1 (hardly) to 5 (very good).
9. Decisions, minutes and materials are accessible to all members:
   • no, only to a few
   • partly or incompletely
   • yes, completely

Expertise and support

10. The team uses training and advice from an external CTC support organisation:
    • never
    • rarely
    • occasionally
    • often
    • regularly and systematically
11. Members have a sound understanding of the concept of risk factors and protective factors: rate from 1 (hardly) to 5 (very good).
12. The team can explain and apply the Social Development Model of Catalano and Hawkins: rate from 1 (hardly) to 5 (very good).

Public communication and local embedding

13. There is a strategy for communicating the CTC work in the community:
    • no
    • in development
    • yes, comprehensive
14. The prevention work appears in local media:
    • never
    • rarely (once or twice a year)
    • occasionally (three or four times a year)
    • regularly (every month or two)
    • often (monthly or more)
15. Local decision-makers know and support the CTC process: rate from 1 (hardly) to 5 (very strongly).

Reading the result. There is no automatic score. For each criterion, note the level that best describes your situation, then look at the pattern across the five areas. Where do the lower levels cluster? Those clusters say more than any total. Criteria at the lowest levels mark the starting point for the next steps, and the table above maps each factor to the phase in which it matters most. It is worth having several participants make the assessment independently: the differences between their answers often show more precisely where perceptions within the team diverge. After six to twelve months, repeat the exercise and compare it with the first round.

The self-check is a starting point for a closer look at the individual factors, not a verdict. Where it exposes weaknesses, targeted improvements can be made and evaluated at the next round. The criteria and the eight factors are based on the implementation recommendations that the Hannover Medical School derived from CTC-EFF (Walter et al., 2025).

Looking ahead

A successful implementation of Communities That Care does not happen by itself. It requires systematic attention to the eight factors set out here, and the good news is that each of them is something a community can act on.

On effects, restraint is warranted. CTC-EFF found no significant system-level effects within its observation period, and behavioural effects have yet to be demonstrated in a European setting (Röding et al., 2026). The data collection coincided with the COVID-19 pandemic and implementation progress in the CTC communities was correspondingly slight; the authors therefore recommend a longer observation period before the question of system effects can be answered. The US trial, with its funded coordinators and its five years of support, remains the benchmark for what a well-resourced implementation can achieve, and the German study is the clearest demonstration so far of what happens when those resources are missing.

For communities introducing or developing CTC, it pays to look at existing examples and to exchange regularly with other CTC sites. The organisations that provide CTC training and support in Europe exist for that purpose. With a strategic approach and consistent attention to these factors, CTC can become a powerful instrument for the psychosocial health of children and young people in your community.

References

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Walter, U., Röding, D., Ünlü, S., Decker, L., & von Holt, I. (2025). Handlungsempfehlungen für die Implementation von Communities That Care [Recommendations for the implementation of Communities That Care]. Hannover Medical School. https://wegweiser-gruene-liste.de/fileadmin/user_upload/wwgl/PDFs/CTC-Handlungsempfehlungen.pdf