Table 1.

D4DS: recommendations and answerable questions

Recommendation	Explanation	Specific action or answerable question
Shifting ways of thinking: How to view the world from a D4DS perspective
Recommendation 1: Begin with dissemination, sustainment, and equitable impact in mind	It is not enough to begin with anticipated health outcomes in mind—begin by asking, Who will influence the decision to adopt and sustain? How will this work ensure equitable impact?	To what extent do specific activities designed to enhance dissemination, sustainability, and equity yield improved health impacts?
Recommendation 2: Prioritize the needs and perspectives of diverse stakeholders at every stage of the process	Involving stakeholders from multiple perspectives, including potential adopters, will help anticipate challenges; keeping stakeholders involved throughout the process should improve quality of adaptations.	To what extent does ongoing involvement—in different ways and at multiple points in time—produce greater impact than more modest or one-time stakeholder engagement?
Recommendation 3: Appreciate the value of a rapid and iterative approach and the need for periodic adaptation	Anticipate and plan for the need to adapt programs or strategies in response to dynamic context over time.	In what ways do approaches that specifically include multiple assessment points for review of results to date and iterative adaptations yield enhanced impact?
Shifting skills and approaches: What we need to do differently to realize the promise of D4DS
Recommendation 4: Incorporate team science and systems science principles and practices	D4DS is a collaborative enterprise and produces products that influence systems of care and health. Team and systems science best practices can help ensure that teams work well together and that they can produce better products.	To what extent do programs and products that incorporate team science and systems science methods produce greater impact?
Recommendation 5: Employ health communication techniques tailored to the intended audience	One size does not fit all, and framing how programs and products are discussed and promoted has a big impact on adoption.	Do products distributed to intended audiences using health communication and audience-targeted strategies produce greater adoption?
Recommendation 6: Evaluate adoption, equity, and sustainment at scale (21)	Transparent reporting and rigorous evaluation of adoption, equity, and sustainment impacts and relationships among them using both randomized and nonrandomized designs are needed (21).	To what extent can the field be advanced by investigations that provide full reporting on all three of these impacts rather than on health impacts only?
Shifting training and evaluation systems and infrastructure: What we need to build to support shifting views, skills, and approaches
Recommendation 7: Establish and promote training programs that acculturate trainees to the D4DS perspective and teach D4DS skills	Training in key issues described in this article (e.g., communications training, systems science, user-centered design, in-depth training in stakeholder engagement) helps promote equity.	To what extent do training programs and activities that include key D4DS competencies produce better, more sustainable results than those that do not?
Recommendation 8: Provide resources to assist programs and policies that inform D4DS and develop practice-based evidence (28)	The above recommendations require support and funding. Infrastructure is needed to accommodate emerging D4DS lessons learned.	To what extent do programs and trainings that provide targeted resources and specific responsibilities for D4DS and continuous evaluation produce more sustainable and equitable impacts?

Abbreviation: D4DS, designing for dissemination and sustainability.