PREVENTION
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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 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

  • 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

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

  • 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

  • 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

  • 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

  • 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

Albee’s equation

Incidence =

Risk factors

Protective factors =

Organic causes + Exploitation + Stress

Coping skills + Self-esteem + Support


  • 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

  • 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


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

A 25-year universal primary prevention policy research demonstration project


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

  • 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

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

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)

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)

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

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

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

What are the annual costs of these programs?

Economic Analysis Research


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

  • 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


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

  • 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

  • In-school

  • Family support

  • Community development


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

  • 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

  • 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

  • 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

  • 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

“… 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

  • 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

Source: Peters et al. (2002)


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

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.”


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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • Barriers

  • Academic-scientific - Lamb and Zusman (1979)

  • Professional-organizational

  • Social-political


  • PREVENTION

  • Critique

  • Person-centred vs. macro-social and political

  • Expert vs. community-driven

  • Focus on outcome vs. implementation


  • 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


  • 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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