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PREVENTION “An ounce of prevention is worth a pound of cure”!. PREVENTION LECTURE OUTLINE Why prevention? Definition Historical perspectives on prevention Risk and protective factors Types of prevention/promotion Barriers to prevention/promotion Critique of prevention/promotion.

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PREVENTION “An ounce of prevention is worth a pound of cure”!

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Prevention an ounce of prevention is worth a pound of cure

PREVENTION

“An ounce of prevention is worth a pound of cure”!


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION LECTURE OUTLINE

  • Why prevention?

  • Definition

  • Historical perspectives on prevention

  • Risk and protective factors

  • Types of prevention/promotion

  • Barriers to prevention/promotion

  • Critique of prevention/promotion


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Why Is Prevention So Important?

  • High prevalence rates for disorders

  • Many people with disorders do not seek treatment

  • Savings in both human misery and costs

  • Not enough trained therapists, and therapy is not 100% effective


Prevention an ounce of prevention is worth a pound of cure

PREVENTION

George Albee’s (1990) Prevention Mantra

“No mass disease or disorder afflicting humankind has ever been eliminated by attempts at treating individuals. . . Primary prevention is an approach to reducing the future incidence of a condition through proactive efforts aimed at groups, or even a whole society.”


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Definition of primary prevention

  • new cases of a problem do not occur; reduction of incidence

  • focus is on population or sub-population, not individuals

  • intentional focus on preventing mental health problems


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Definition of mental health promotion

  • focus on strengths, not problems; wellness, not illness

  • focus is on population or sub-population, not individuals

  • multidimensional – from individual to society

  • ongoing, not time-limited


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Historical perspective

  • pre-germ theory – possible to do prevention without knowing causes – e.g., scurvy, Snow and the Broad St. pump, Semmelweiss

  • public health approach – the host, the environment, the agent


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Risk and protective factors (diathesis-stress)

  • risk factors – those that increase the likelihood of disorder

  • protective factors – those factors that help to buffer or offset the impacts of risk factors

  • ecological perspective – micro, exo, macro (bio-psycho-social)


Prevention an ounce of prevention is worth a pound of cure

PREVENTION

Albee’s equation

Incidence =

Risk factors

Protective factors =

Organic causes + Exploitation + Stress

Coping skills + Self-esteem + Support


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Risk and protective factors – mechanisms for promoting wellness and preventing problems (Rutter, 1987)

  • reducing risk impact

  • interrupting unhealthy chain reactions

  • enhancing self-esteem and self-efficacy

  • creating opportunities for personal growth


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Types of promotion and prevention – Strategies for promoting wellness (Cowen, 1994)

  • promoting attachment

  • building competencies

  • enhancing social environments

  • fostering empowerment

  • providing resources to cope with stress


Prevention types of promotion and prevention strategies for prevention

Primary prevention

Secondary

Tertiary

Universal – population-wide

Selective – high-risk approach

Indicated – early detection and intervention (not true prevention)

Treatment – problem is well established

PREVENTION Types of promotion and prevention – Strategies for prevention


Better beginnings better futures

Better Beginnings, Better Futures

A 25-year universal primary prevention policy research demonstration project


Prevention an ounce of prevention is worth a pound of cure

There is much rhetoric about the importance of programs beingcomprehensive, ecological, holistic, community-based, collaborativeand/orintegrated

  • However, there are virtually no well-researched programs for young children which have successfully incorporated these characteristics into the program model


Programs and evaluations need to be more ecological

Programs and evaluations need to be more ecological

  • Consider development of “whole child” – physical, social, behavioural, cognitive and emotional development and well-being

  • Parent and family functioning and characteristics

  • Neighbourhood characteristics and change


Better beginnings better futures goals

Better Beginnings, Better Futures: Goals

Prevention

  • To reduce the incidence of serious, long-term emotional and behavioural problems in children

    Promotion

  • To promote the optimal social, emotional, behavioural, physical and educational development in children

    Community Development

  • To strengthen the ability of disadvantaged communities to respond effectively to the social and economic needs of children and their families


Program model

Program Model

High Quality Programs

  • For children from conception to age 4 or from age 4 to age 8 and their families

    Integrated Programs

  • Service organizations and providers “blend and unite”

    Community Involvement

  • Parents and other citizens participate as equal partners with service-providers in planning, designing and carrying out programs for children and families in the local community


Younger child sites 0 4yrs

Younger Child Sites (0-4yrs)

Guelph:Willow Road

  • 625 children

    Kingston:Northern Area

  • 1095 children

    Ottawa: Albion- Heatheringrton-Farlea-Ledbury

  • 690 children

    Toronto: Moss/Regent Park

  • 1125 children

    Walpole Island First Nation:

  • 250 children


Older child sites 4 8yrs

Older Child Sites (4-8yrs)

Cornwall: 4 Francophone primary schools

  • 530 children

    Etobicoke: Highfield Junior School

  • 517 children

    Sudbury: Flour Mill/le Moulin à Fleur and Donovan

  • 503 children


Research question 1

Research Question 1

How do the Better Beginnings communities develop and implement programs? Are they characterized by:

  • Parent and community involvement?

  • Integration of services?

  • High quality programs?

    Project Development & Program Model Research


Research question 2

Research Question 2

Are the Better Beginnings programs effective in:

  • Preventing serious problems in young children?

  • Promoting healthy child and family development?

  • Enhancing the abilities of disadvantaged communities to provide for children and their families?

    Outcome Evaluation Research


Research question 3

Research Question 3

What are the annual costs of these programs?

Economic Analysis Research


Research question 4

Research Question 4

What are the long-term effects and cost-benefits for children and their families in terms of:

  • Educational achievements and high school graduation rates?

  • Use of special education, health, and social services?

  • Employment and social assistance?

  • Criminal charges and convictions?

  • Teen pregnancy?

  • Drug and alcohol abuse?

    Long Term Follow-up Research


Low and declining family income

Low and Declining Family Income

  • 1990 mean family income for Highfield was $43,841, compared with the provincial average of $57,227

  • 1995 mean family income for Highfield was $36,054, compared to the provincial average of $59,830


Unemployment rates

Highfield

1991 - 14.1% for men

1991 - 12.6% for women

1996 - 13.3% for men

1996 - 17.5% for women

Ontario

1991 - 8.6% for men

1991 - 8.4% for women

1996 - 8.7% for men

1996 - 9.6% for women

Unemployment Rates


A culturally diverse community

A Culturally Diverse Community

  • 1991 - 53.6% born outside Canada

  • 1995 - 59.8% born outside Canada

  • 9 languages were mother tongue to 100 people or more


Major program components

Major Program Components

  • In-school

  • Family support

  • Community development


In school programs

In-school Programs

  • Staff coordinator and committee of parents, teachers and other service-providers oversee in-school programs

  • Nutrition program - snack, breakfast, hot lunch, classroom instruction

  • School-wide social skills program - Lion’s Quest

  • Educational assistants in primary grades

  • Summer programs

  • Translation services for parent-teacher conferences


Family support programs

Family Support Programs

  • Staff coordinator and committee of parents and other service-providers oversee family support programs

  • Family Resource Centre - including toy lending library, parent relief, drop-in, parenting programs conducted in different languages by staff from different cultural backgrounds

  • Family enrichment workers provide home visitation and bridge home and school


Community development programs

Community Development Programs

  • Staff coordinator and committee of parents and other service-providers oversee community development programs

  • Before and after-school programs

  • Cultural celebrations

  • Volunteer coordination and recognition

  • Field trips

  • Resident participation and leadership development


Significant child findings

Significant Child Findings

  • Fewer emotional and behavioural problems (as rated by parents)

  • Enhanced social skills (according to both parent and teacher ratings)

  • Significant improvements in children’s health


Significant parent findings

Significant Parent Findings

  • Decrease in hostile-ineffective parenting

  • More consistent parenting behaviour

  • Greater satisfaction with parenting

  • Reduced tension/stress

  • Less depression

  • More social support

  • Improved family functioning


Enhanced self esteem

Enhanced Self-esteem

“… Sitting on various committees and actually having people seem like they were listening to me … I started getting respect for the first time in a long time.”


Significant neighbourhood and school findings

Significant Neighbourhood and School Findings

  • Decrease in percentage of special education students

  • Improved relationships between parents and children’s teachers

  • Greater parental involvement in the school

  • Enhanced parent perceptions of school

  • Greater satisfaction with condition of housing

  • Decrease in arrests for break-in & vandalism

  • Reduction in proportion of CAS cases & children-in-care from Highfield neighbourhood


Impacts on child maltreatment number of open cas cases in highfield community over time

Impacts on Child Maltreatment: Number of Open CAS Cases in Highfield Community over Time

Source: Peters et al. (2002)


Outcomes for the project

Outcomes for the Project

Programs that are better designed and utilized

“…They (the residents) feel a little more for the project, than people who are just working there … It’s probably moved a lot faster … The home visitors wouldn’t have anywhere to go if parents weren’t involved … The project would have flopped because the parents wouldn’t have anything to do with it.”


Outcomes for the community

Outcomes for the Community

Building a sense of community

“…I really think before this (Better Beginnings) was in place it was pockets of people … I think the neighbourhood is now starting to think of itself as a community, and I don’t think it was doing that before.”


Prevention an ounce of prevention is worth a pound of cure

Comparison of Better Beginnings Program Costs with Other Prevention Programs and Ontario Funded Services

Programs/ServicesCosts in 1997 Cdn Dollars

Better Beginnings, Better Futures$1,100-$2,000/child or family year

Highfield Community Enrichment Project$2,000/child or family year

Perry Preschool Project$8,600/family/year

Elmira (NY) Home Visiting Project$4,300/family/year

Ontario primary school$7,000/child/year

Full-time licensed childcare in Ontario$8,500/child/year

Ontario JK & SK $3,200/child/year


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Prenatal/Early Infancy Project – the program

  • first-time mothers in poor, rural community in upstate NY

  • 3 risk factors - low-income, unmarried, or teen age

  • nurse home visitation began prenatally, roughly 50 visits up to time child was age 2


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Prenatal/Early Infancy Project – short-term findings

  • after 2 years, 14% of high-risk women in the control group abused or neglected their children compared to 4% of high-risk women in the control group

  • after 4 years, significantly fewer nurse-visited children had injuries compared with those in the control group


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Prenatal/Early Infancy Project – short-term findings

  • reductions in repeat pregnancies and increases in work force participation for nurse-home visited women compared with those in the control


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Prenatal/Early Infancy Project – long-term findings

  • 15 years later, compared with mothers in the control group, nurse-home visited mothers had

  • higher rates of employment

  • lower rates of impairments due to alcohol or substance abuse (41% vs. 73%)


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Prenatal/Early Infancy Project – long-term findings

  • lower rates of verified child abuse or neglect (29% vs. 54%)

  • lower rates of arrests (16% vs. 90% according to state records!)

  • and lower rates of convictions, days in jail, and use of welfare


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Prenatal/Early Infancy Project – long-term findings

  • 15 years later, compared with children in the control group, children whose mothers received nurse-home visits had

  • lower rates of running away (24% vs. 60%)


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Prenatal/Early Infancy Project – long-term findings

  • lower rates of arrests (20% vs. 45%)

  • lower rates of convictions and violations of probation (9% vs. 47%)


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Perry Preschool – the program

  • Poor, African-American children, ages 3 & 4, and their families in Ypsilanti, Michigan

  • Preschool educational program + weekly home visitation


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Perry Preschool – short-term findings

  • kindergarten and gr. 1 - children who participated in the program performed better than control children on measures of IQ and academic readiness

  • by grades 3 & 4, no differences between preschool and control groups


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Perry Preschool – long-term findings

  • by age 19, compared with control children, children who had been in the program were more likely

  • to be employed, attending college or university

  • to have higher rates of high school graduation

  • and lower rates of arrest and teen pregnancy


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Perry Preschool – long-term findings

  • by age 27,

  • three times as many participants in the Perry Preschool Program as control participants earned $2000 or more per month (29% vs. 7%)

  • owned their own homes (36% vs. 13%)

  • while five times as many control participants had five or more arrests than project participants (35% vs. 7%)


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Selective – Perry Preschool

  • for every dollar invested in the 30 week program, $6 return from savings from lower special education, criminal justice and welfare costs


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Barriers

  • Academic-scientific - Lamb and Zusman (1979)

  • Professional-organizational

  • Social-political


Prevention an ounce of prevention is worth a pound of cure

  • PREVENTION

  • Critique

  • Person-centred vs. macro-social and political

  • Expert vs. community-driven

  • Focus on outcome vs. implementation


Prevention an ounce of prevention is worth a pound of cure

  • SUMMARY OF PREVENTION

  • there is growing evidence that prevention can reduce the incidence of serious risk factors for mental disorders (e.g., child maltreatment), mental disorders (e.g., antisocial personality, substance abuse)

  • that promotion can enhance social competencies (e.g., children’s social skills, parenting skills) and build community capacity


Prevention an ounce of prevention is worth a pound of cure

  • SUMMARY OF PREVENTION

  • there is also evidence that prevention and promotion are cost-effective in the long-run

  • but prevention and promotion continue to underfunded relative to treatment services

  • moreover, many of those prevention programs that are funded are not adequately funded to provide sufficiently long and intensive to be maximally effective


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