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 (diathesisstress)
• 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
PREVENTION
Types of promotion and prevention –
Strategies for prevention
Primary
prevention
Universal – populationwide
Selective – high-risk
approach
Secondary
Indicated – early
detection and
intervention (not true
prevention)
Treatment – problem is
well established
Tertiary
Better Beginnings,
Better Futures
A 25-year universal primary prevention
policy research demonstration project
 There is much rhetoric about the
importance of programs being
comprehensive, ecological,
holistic, community-based,
collaborative and/or integrated
 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:
AlbionHeatheringrton-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
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
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
35
30
25
20
15
10
5
Source: Peters et al. (2002)
19
97
19
95
19
93
19
91
19
89
19
87
0
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/Services
Costs 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 nursevisited 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