Prevention

1. Prevention Doing something now can avert more serious problems in the future • Promises proactive efforts that reduce the • overall suffering of the population • Potentially cost-effective, more people • become contributing members of society • Interest in prevention continues to grow • Public health movement of the 19th century

2. Historical View – to 1960s • Looked at applying the medical prevention model • to mental disorders • In 1961 the Joint Commission on • Mental Health recommended a • preventive approach to reducing • mental disorders • Head Start (1965) • In 60s social inequality and injustice were seen as • contributors to the development of mental disorders • We would never have enough trained professionals • to address all the mental health needs so • prevention became the path to overall wellness

3. Historical View – 1970s • Proponents wanted clearer definitions • of prevention and research • Opponents argued that prevention did • little more than help a few individuals • lead happier lives • Challenged whether prevention merited funding • Objected to the social change agenda - there was no • proof that life circumstances lead to mental illness • George Albee - Those for the status quo want to • avoid the social changes required to eradicate • poverty, racism and other social conditions that • undermine mental health.

4. Historical View – 1980 to 90s • Publications supported implementation of the prevention model: • Journal of Primary prevention • Prevention in Human Services • 14 Ounces of Prevention: A Casebook for • Practitioners • Definitions of prevention were tightened • Prevention research became more rigorous • In the 1990s, the prevention model came of age

5. Meta-analysis Support • A research technique that collapses data across many studies in order to obtain an overview of the magnitude of effects. • Durlak & Wells assessed over 300 interventions: • Participants who did not show signs of disorder significantly surpassed the performance of 59-82% of the control group • Participants showing initial signs of maladjustment out performed 70% of control participants • Institute of Medicine review of federally-sponsored research showed that prevention programs were effective and merited federal funding

6. Prevention Topologies Incidence – the number of new cases that arise in a population during a specified period Prevalence – total number of cases in a population at a specified time; reflects the incidence and duration of the disorder

7. Primary, Secondary, Tertiary Prevention • Gerald Caplan (1964) • Tertiary prevention – after the disorder has • developed • Secondary prevention – early intervention • Primary prevention – targets people who do not • show signs of the disorder • Problems with this model: • Tertiary prevention for one is primary for another • When are at-risk populations healthy or showing • early indicators of a problem

8. Indicated, Selective, Universal Prevention • Institute of Medicine (IOM) report • Defines an intervention continuum • Tertiary intervention no longer qualifies as prevention • Secondary prevention is divided into Indicated and • Selective prevention • Cowen (1983) – although the goals of reducing the adverse consequences of disorder are neither unworthy or unneeded, they are simply not prevention”

9. Indicated Prevention • Targets people who have detectable signs of maladjustment that foreshadow more significant mental disorders or who have biological markers that are linked to the disorder • Examples • Fetal Alcohol Syndrome prevention • Primary Mental Health Project • Substance Abuse prevention

10. Selective Prevention • Targets people who are at high-risk for developing a disorder but do not yet show any indications of the disorder. • Risk is assessed by evaluation of biological, psychological and/or social risk factors. • Examples • STEP • Binge Drinking • DARE • Bullying

11. Universal Prevention • Corresponds to primary prevention, targets all of the people in a given population • Reach large numbers of people • Cost little per individual and are effective • Acceptable to the general population • Little risk of negative outcomes • “Best Practice” interventions - strategies and programs that are deemed promising based on the results of high-quality research • Examples • Just Say No • Eating Disorders • Identity theft

12. Primary Intervention and Promotion • Attempt to reduce the likelihood of disorders • Reduce risk levels by helping people and • communities develop skills and competencies • HIV/AIDS education • Bullying • Teen suicide • Acceptance • Safe Sex • Obesity Competence building is the single most persuasive preventative strategy for dealing with individual and social issues

13. Dohrenwend Revisited • Serves as a third topology for organizing prevention research and practice. • Tertiary Prevention • Mutual help groups • Corrective therapy • Secondary/Selective Prevention • Disaster relief

14. Dohrenwend(cont’d) • The remaining four interventions do not need stress to occur before implemented. • They affect the context of stress at the individual or environmental level. • They can either prevent the occurrence of stress or facilitate the capacity to adjust after the stress occurs. • Skill training • Education and socialization • Community organization and development • Political action

15. Assessing Risk • In public health, specific disorders develop from single causes • Mental health prevention cannot be traced to a single pathogen, they result from complex interactions of multiple individual and environmental factors • Selective and indicated programs need to know what leads to disorder or strengthens health, under what circumstances

16. Risk Factors • Associated with higher likelihood of a problem, greater severity and duration once the problem occurs • Individual and • environmental factors • that act together

17. Generic Risk Factors Family Circumstances • Low Social Class • Family Conflict • Mental Illness in family • Large family size • Family Disorganization • Communication Deviance Interpersonal Problems • Peer rejection • Alienation and isolation Emotional Difficulties • Child Abuse • Apathy • Emotional blunting • Emotional immaturity • Stressful life events • Low self-esteem • Emotional dyscontrol School Problems • Academic Failure • Scholastic demoralization

18. Generic Risk Factors Skill Development Delays • Subnormal intelligence • Social incompetence • Attentional deficits • Reading Disabilities • Poor work skills and habits Ecological Context • Neighborhood disorganization • Racial injustice • Unemployment • Extreme poverty Constitutional Handicaps • Perinatal complications • Sensory disabilities • Organic handicaps • Neurochemical imbalance

19. Assessing Risk • Protective factors • Variables that improve resistance to risk factors and disorder • Can modify or influence the disorder by affecting the risk factors, buffering or preventing their occurrence • Predisposing factors • Long-standing characteristics of a person’s make-up or environment • Genetic component or personal background factors • Increase vulnerability • Precipitating factors • Stressful occurrences that trigger the disorder

20. Prevention Equation George Albee (1982) – Incidence of Psychological Disorder = Stress + Physical Vulnerability Coping Skills + Social Support + Self-esteem Maurice Elias (1987) - Likelihood of Disorder in Population = Stress + Risk Factors in Environment Socialization Practices + Social Support Resources + Opportunities for Connectedness

21. Attributable Risk • The number of new cases of a disorder that would be prevented if an intervention completely eliminated a risk factor • Assessment of attributable risk helps target interventions at factors that lead directly to a problem • Smoking lung cancer, emphysema, throat cancer, house fires, second-hand smoke; • Poverty domestic violence, school failure, criminal behavior, mental illness, substance abuse

22. Readiness to Change • Pre-contemplation • Contemplation • Preparation • Action • Maintenance

23. Community Readiness to Change Community Tolerance/No Knowledge Denial Vague Awareness Preplanning Preparation Initiation Institutionalization/stabilization Confirmation/Expansion Professionalization

24. Assessing Effects • Preventative Intervention Research Cycle • Identify the problem or mental health outcome, its prevalence and course over the lifespan • Review relevant research on risk and protective factors across disciplines • Develop and implement pilot interventions and test the efficacy • Design, implement, and analyze effectiveness of promising interventions in large-scale trials • Implement and continually evaluate prevention programs and disseminate these findings

25. Challenges to the Research Agenda • Emory Cowen (1983) – delineated some of the “research-weakening vicissitudes” of community-based prevention efforts • Difficulties finding appropriate control groups • Antagonism between researcher and community • needs • Attrition of participants • Changes during course of the intervention that are • attributable to the program

26. The Challenge of Follow-up • When can researchers say with confidence that a problem has actually been prevented and not just postponed? • Proximal outcomes • Distal outcomes • Lifespan development • Problem development

27. Iatrogenesis The occurrence of unintended but deleterious effects of an intervention or program • Labeling • Overreacting • Net-widening • Insensitivity to context

28. Ensuring Program Integrity • Ethical guidelines: • Do no harm • Program should not be designed for preventionist gain • Piloted in small-scale studies to ensure effectiveness • Participants should be treated with respect and active in planning, implementation and evaluation of the program • Program planners, participants and others are entitled to professional courtesies, particularly confidentiality • Informed consent should be obtained before implementation of the program • The program should promote equality and justice • The preventionist is accountable for the impact of the program and must resolve any problems that result

29. Program Popularity & Efficacy • Public and political support does not depend on evidence of efficacy. • Juvenile boot camps, Zero Tolerance school policies • and school-based sexual abuse programs are • widely popular without evidence of effectiveness • DARE (1983) • By 1990 in 3000 communities in 50 states • 1990’s reports of ineffectiveness, small short • term effect on drug use • Program evaluators, researchers worked with • DARE to reformulate its program based on • sound research and program evaluation

30. Program Evaluation Program evaluation is carefully collecting information about a program or some aspect of a program in order to make necessary decisions about the program. Program evaluations can address: needs assessments, accreditation, cost/benefit analysis, effectiveness, efficiency, processes, outcomes, etc. The type of evaluation you undertake depends on what you want to learn about your program. Don't worry about what type of evaluation you need or are doing -- worry about what you need to know to make the program decisions you need to make, and worry about how you can accurately collect and understand that information.

31. What Program Evaluation Does Verification that the programs are indeed helping constituents. Improve delivery mechanisms to be more efficient and less costly. Identify program strengths and weaknesses to improve the program. Verify that you're doing what you think you're doing. Facilitate thinking about what the program is all about including its goals, and how it will know if it has met its goals or not. Produce data that can be used for public relations and promoting services in the community. Produce valid comparisons between programs to decide which should be retained in the face of pending budget cuts. Examine and describe effective programs for duplication elsewhere.

32. Evaluation Methods Process-based - geared to fully understanding how a program works - how does it produce that results that it does. Goal-based - evaluate the extent to which programs are meeting predetermined goals or objectives Outcomes-based - Increasingly important for nonprofits and asked for by funders. Facilitates asking if your organization is really doing the right activities to bring about the outcomes you believe to be needed by your clients

33. Data Collection Methods: Questionnaires, Surveys, Checklists

34. Data Collection Methods: Interviews

35. Data Collection Methods: Documentation Review

36. Data Collection Methods: Observation

37. Data Collection Methods: Focus Groups

38. Data Collection Methods: Case Studies