Week 8: Prevention as an intervention approach

Romano and Hage define prevention efforts as having one or more of the following five dimensions

1. Prevents a problem behaviour from ever occurring. 2. Delays the onset of a problem behaviour. 3. Reduces the impact of an existing problem behaviour. 4. Strengthens knowledge, attitudes, and behaviours that promote emotional and physical well-being. 5. Supports institutional, community and government policies that promote physical and emotional well-being.

ecological or macro-level interventions

- These are aimed at changing the contexts in which people live, and includes social norms, habits, policies and community structures. - The assumption is that people and their contexts are in a process of interdependent interaction. - An example of this is the provision of clean water to a community, to prevent sickness associated with unclean water supplies. - Macro interventions are large-scale and have a long-lasting impact on the community.

prevention as an intervention strategy

- From a public health perspective, disease can be prevented by strengthening or immunising the host, removing a pathological agent, or by environmental modification. - The prevention model applies these same principles to mental health and disorders. o This assumes a proactive role, rather than a reactive role. - Prevention is also future-oriented since prevention means to anticipate something before it happens. - Preventive intervention can be described as a planned, proactive activity designed to prevent or reduce future harm. - Traditionally, the preventive approach can be classified as part of the mental health model where professionals aim to intervene to improve mental health.

systems empowerment

- Involves actions, human rights groups that are mobilised to take action and self-help groups that bring people with similar needs together. - The people are made aware of their position in the group and the power they have to obtain resources.

booster sessions

- Short-term interventions achieve short-term results. - Consequently, regular "booster" follow-up sessions should be added to help maintain the effects of the initial intervention.

the empowerment model

- The empowerment model developed in reaction to the mental health model where experts were used to determine the needs of a community and designed interventions without consulting participants.

basic assumptions of the empowerment model

All people and communities have the capacities to make their own decisions. o Malfunctioning in a community is due to a lack of resources and social structures. o Solutions to community problems are diverse. o The community itself should decide which solutions it should implement. - Solutions are problem and context-specific.

problem with the classification systems

initially designed for physical disorders. o It is more difficult to identify the cause and origin of a psychological disorder than a physical disorder.

preventative strategies can be classified in 3 ways:

o According to the goal of the programme. o According to the target population of the intervention. o According to the level of intervention.

risk continuum

o Includes: prevention, early intervention, and treatment of problem. o Different conceptual frameworks for prevention: - According to the goal of the intervention. - According to the target population of the intervention.

prevention accroding to Caplan

o Primary prevention reduced the incidence of mental disorders of all types in a community. o Secondary prevention (early intervention) reduced the duration of a significant number of those disorders which do occur. o Tertiary prevention (treatment programs) reduces the impairment which may result from these disorders.

principles of empowerment

o That people have more control over their lives. o It involves building self-reliance and the capacity to achieve goals. o It enhances access to resources. o It is a process of development. o It enhances the rights of citizens. o It is a collective, social process. - The empowered person is an individual who believes that he or she has the ability to do a certain task and this belief is accompanied by competent behaviour.

the approach continuum

• This identifies various intervention approaches to the problems that may appear at each level of risk: - universal approaches, selected approaches, booster sessions, indicated treatment approaches, and second-chance approaches.

empowerment

"Empowerment is a mechanism whereby people, organisations and communities gain mastery over their own affairs" Rappaport (1987) - Empowerment is the process by which people, organisations, or groups who are powerless or marginalised become aware of the power dynamics at work in their life contexts, develop the skills and capacity for gaining some reasonable control over their lives, which they exercise, without infringing on the rights of others, and which coincides with actively supporting the empowerment of others in their community. - On a community level, empowerment involves community members gaining a voice in political affairs that affect their lives. - Participation: a mechanism to promote empowerment. How do we understand the term 'empowerment'? - by examining its principles and assumptions.

family component

- Here, prevention, early intervention and treatment also form a continuum. - Examples of prevention strategies include strategies designed to strengthen families by encouraging communication and stability. - Examples of early interventions include social and emotional support programs, as well as training in parenting skills. - Examples of treatment strategies include programs designed to address child abuse and neglect, parental dysfunction and family violence.

participatory compentence

- A person needs behavioural skills to participate effectively in community decisions. - These skills include being able to articulate community problems, assertively expressing your own views, building collaborative relationships, encouraging teamwork, mobilising resources and managing conflict

Critical Awareness

- Being able to question assumptions about social relationships and to recognise disabling discourses in the community. - This involves becoming aware of injustices, social irregularities, one's own position in a community and the processes within a community. - It involves a critical judgement of situations, a search for the underlying causes of problems

difference between the two classification systems

- Caplan's classification system uses the terminology primary, secondary and tertiary prevention to distinguish between interventions that reduce incidence rates or new cases of a problem, prevalence rates in high risk groups, or interventions that reduce the harmful effects of an existing problem. - Gordon's classification system focuses on the target group for the prevention intervention and uses the terminology universal, selected and indicated to distinguish between interventions that target every individual in the defined population, individuals or subgroups within the defined population, or groups at high risk of experiencing the problem within the defined population.

criticisms of the concept of empowerment

- Criticisms of empowerment include that it can lead to individualism, and consequently, competition and conflict. - Also, contextual inequalities can impair empowerment, such as inequalities between community members based on education, socioeconomic status and knowledge. - Also, psychologists tend to have more power due to their access to knowledge and information, which also creates a discrepancy between them and the community.

Durlak and Wells stress 2 ways of providing primary prevention

- Decreasing risk factors that can contribute to the development of psychological problems. 〆 Risk factors can be defined as those features of individuals and environments that reduce the biological, psychological and social capacities of individuals to maintain their own wellbeing. - Promoting the coping abilities of individuals to enhance mental health. 〆 Protective processes are those features of individuals and environments that operate in ongoing ways to increase or enhance the capacity of individuals to maintain their wellbeing.An example of this would be a workshop presenting life skills to primary school learners.

school component

- Examples of prevention strategies include adequate preschools, compensatory programs, and before- and after-school programs. 〆 These school-based interventions are enhanced when there is collaboration between schools and homes. 〆 For teachers and parents to work together successfully, we need adequate communication, skills, time, resources, empathy and patience. - Often, these programs include parent liaisons (paraprofessionals from the local community who support teacher-parent interactions and facilitate meetings between teachers and parents). - early intervention is necessary for targeted children in specific problem situations or for those who exhibit problem behaviour. - As children develop, efforts shift from universal to selected programs (which should begin by grade 3). - As young people progress through school, indicated treatment programs are required.

environmental settings

- In the comprehensive framework (page 81 of Book 1), we attend to the environment by including society/ community, family and school, as well as the relationship between these components. - In each of these components (represented by a rectangle), we have an intervention continuum consisting of early, broad-based prevention; early intervention efforts to co-ordinate support and training activities; and treatment approaches. - In these rectangles, we have an ascending diagonal line which indicates different strategies - some are best implemented earlier and are thus less effective later, others are less effective at early interventions and must thus be implemented at a later stage. o Early intervention falls in the middle of this line, between prevention and treatment.

individual empowerment

- Is achieved through humanistic psychotherapy, training in behaviour skills and awareness actions that help individuals change their behaviour and take more control of their lives.

main qualities of primary interventions

- Occur before any problem exists, - Focus on healthy people or those at risk, - Are group-oriented and population based, - Are implemented to reduce the incidence of new dysfunctions from occurring, - Are designed to increase protective factors and decrease risk factors, - Are ecological and systemic (occurring within various interactive levels of influence), - Should be culturally sensitive and valid, - Are collaborative, educational and empowering, and - Are concerned with social justice.

the prevention-treatment approach

- Prevention, early intervention and treatment programs also form a continuum. - These terms correspond with Caplan's "primary, secondary and tertiary preventions". - Prevention: o To prevent problems before they start. o Upstream approach-preventative - Need to go to the origin/root cause of problem (go upstream). o Proactive approach, NOTreactive. - But also, reactive because prevention exists on a continuum because risk exists on a continuum. o To support and maximise the impact of protective factors and reduce the impact of risk factors.

At-Risk Continuum

- Problems faced by young people can be placed on this continuum, from minimal risk to actual participation in an activity in one of the at-risk categories. - A remote degree of risk is associated with certain demographic characteristics. - As young people mature, personal characteristics that lead to increasingly higher risk may become evident. - If these characteristics are not modified, the individual may move to remote risk or high risk. - The end of this continuum describes adolescents who have already started engaging in a risk behaviour.

creating conditions for empowerment

- The empowerment process is characterised by the recognition and fostering of strengths and competencies, recognition of the wisdom of everyday experience, the promotion of diversity and a fostering of community ties. - An essential component of empowerment is the attitude of the consultant. - This is expressed through believing in the community's capacity to solve its own problems, allowing the community to do what it can for itself, helping the community to develop leadership, and facilitating problem-solving skills in groups using a democratic approach. - Empowerment can also be achieved by using action research, as the community has to actively participate in the intervention to help solve problems.

second chance approaches

- These are aimed at children and adolescents that are engaging in substance abuse, have dropped out, fallen pregnant, or are engaging in violent and aggressive behaviours. - Those who have made poor choices need an opportunity to change. - These interventions are most successful when they are comprehensive and cover a broad range of risk and protective factors. - Example: Dream School SA - The intent of such approaches is to set individuals on new paths as early as possible, to open opportunities, to modify life circumstances and to aim for long-term change.

high risk groups or indicated interventions

- These are aimed at individuals or groups that can be seen as vulnerable or at risk of developing certain problems - high risk groups (identified through research). - People who have already started engaging in the problem behaviours. - It aims to decrease risk factors, or their impact. - The problems with this approach hinges on two possibilities: that psychologists will either over predict or under predict. - In other words, community psychologists may select certain individuals for the intervention that were never at risk in the first place. - On the other hand, people who need the intervention may go unnoticed and are not chosen for the intervention. - E.g. flu vaccinations for people at high risk.

person-centered or micro-level interventions

- These are aimed at the individual and his/her immediate environment. - The goal is to help individuals or groups develop the skills and competencies needed to cope with particular situations. - The assumption is that skills and competencies will help the person to adjust to and function effectively in stressful situations.

community-wide interventions

- These are aimed at the population as a whole (community), regardless of individual's level of risk. - An example of this is the Arrive Alive campaign that prevents drunk driving or storm warnings, and water conservation campaigns. - The advantage to this is that a large audience can be reached. - However, it may be expensive and there is no guarantee that those at risk will be reached. - Minimal or remote risk.

tertiary prevention

- This aims to minimise the negative impact of a disorder on an individual's life, or prevent a relapse into the acute phase of the disorder. o It involves treatment or a rehabilitation strategy, and the focus is on the individual, with the hope of reducing the long-term consequences of the disorder. o For example, educate people about how to be active, eat healthy, etc. counselling and support programmes.

society-community component

- This component interacts with the other two, but encompasses the community and larger society. - Examples of prevention efforts on this level include improving socio-economic conditions; increasing the supply of low-cost housing, child care, job opportunities and career options; providing community social support programs; and developing healthy community norms and values. - Examples of early interventions include community programs that involve family members and school personnel, to provide social support, as well as co- ordinated programs that enable community members to assist young people. - Below the diagonal line, is treatment strategies that include system-level interventions, such as empowerment and social activism. - While empowering young people is a preventative approach on the individual level, it is a treatment on the society-community level. - The target of these treatment strategies is not individuals, but norms, structures and practices of organisations, communities, societies and the nation.

selected approaches

- This is the most appropriate approach when a child shows high risk. - These are aimed at groups of young people who share some circumstances or experience that increases the probability that they will develop problems in the future. - Demographic parameters, environmental stressors and skills deficit indicate the need for target prevention programs. - For example, children from homes where there has been acrimonious divorce, mental health problems, alcoholism or drug abuse are quite vulnerable. - In these cases, individual or group counselling, as well as school support programs are very useful. - Children who have a deficit in skills are often described as lonely, depressed, anxious, aggressive, learning disabled or behaviour disordered. - They have limitations in the five C's: critical school competencies, concept of self, connectedness, coping and control skills. - Interventions targeting these children should include skill acquisition, skill performance, removal or reduction of competing problem behaviours, and generalisation and maintenance of skills. - These children are especially suited for selected approaches. - The risks, problems and needs of the selected group must be identified before an appropriate intervention can be designed and implemented.

indicated treatment approaches

- This is the most appropriate approach when a child shows imminent risk or engages in at-risk activities. - This can then be followed by a second-chance program. - These interventions must be developed for young people whose underlying characteristics, problems and behaviours are associated directly with at-risk activity. - This approach addresses attitudes and skills that are particularly relevant for each at-risk category. - It also teaches alternative behaviours and coping skills specific to the problem.

universal approaches

- This is the most appropriate approach when a child shows minimal or remote risk. - It is also appropriate for all children, and not just those at risk. - Here, the intent is to maintain or increase the educational achievement, prosocial coping skills and mental health of large numbers of children. - The content of these programs is integrated through a comprehensive, health- orientated school curriculum. - These programs are also beneficial at any time in the life of a young person, as it teaches basic life-skills competencies to help young people respond to a variety of social situations in a healthy way.

Milestone or life transition intervention (selective strategies)

- This targets people who are at a certain developmental stage or are undergoing a specific crisis. - Target is sub-groups who have a higher than average risk of developing problems. - May correspond with phase in life course. - Focus on transition. - To provide support during this transitional phase. - People are especially vulnerable during transitions, e.g. puberty. - Here, the emphasis is on the interaction between the person and the situation.

community psychology

- community psychology locates the root or cause of such problems in the environment or social context, - which it defines as being multi-level, with the individual embedded in multiple settings that impact his or her wellbeing through risk factors that reside in each of these settings. - characterised by ecological or systems thinking, which we were introduced to through the person-in-context approaches of Lewin's equation and Bronfenbrenner's model. - These systems are dynamic, and there is an ongoing process of interaction across different levels of the system, with each level influencing the other. - The influence between the individual and the multiple levels of the system in which he or she is embedded is therefore bidirectional. - Identifying and addressing risk factors lies at the heart of analysis and intervention in community psychology.

risk factors

- defined as any threat to the health and well-being of individuals, groups, and communities. - They are factors that may include aspects such as demographic characteristics, economic conditions, social and political conditions, environmental stressors, and personal characteristics. - The complement to risk factors is protective factors.

protective factors

- supportive resources that exist, also at multiple levels, and that buffer the individual, group, and community from the impact of risk factors. - In our interventions, we focus on strengthening individuals, groups, and community systems by developing and amplifying protective factors in the system so that we improve the resilience of the system. - Our goal is to offset the impact of risk factors on the system with the introduction and development of protective factors. - Prevention efforts that support and maximise protective factors while reducing risk factors are most likely to be successful. - Individual protective factors e.g. social skills, intelligence. - Familial factors e.g. authoritative parenting, strong attachments between parents and children. - Community factors e.g. accessible resources (social and medical services, parks), strong linkages between family and community.

secondary prevention

- this consists of efforts to detect problems early, before they become serious, and prevent their development into chronic disabilities - to intervene early. o It is a treatment-based strategy that aims to reduce prevalence rates by reducing the total number of people with the problem. o Early detection of problems. o To reduce length and severity of disorder. o Quick and accurate identification of the problem. o Intervening with youth who are at high risk of drug abuse. o An example of this would be a 24-hour emergency service, like LifeLine, or peer education intervention with young people at risk of HIV-infection.

goal of community intervention (Radebe reading)

- to facilitate change in a community in order to improve the mental health in that community. The two specific aims of interventions include: - The prevention of psychological problems, and -the empowerment of the community.

One possible model that can be used in designing an empowering intervention is suggested by Suzuki (1987), and consists of four factors needed for empowerment:

1. Being willing: This implies voluntary participation from the community. 2. Being able: This implies that the community has the required skills, knowledge and resources. 3. Being accountable: This implies that the community is accountable and responsible for the implementation of interventions. 4. Being allowed: This implies that groups that could inhibit the intervention (such as rival groups) are not active or present.

2 classification systems of prevention

1. Caplan (1964) 2. Gordon (1987)

qualities of empowerment

1. Multilevel construct: collective context o It occurs in individuals, organisations and communities. o Empowerment at one level does not necessarily mean empowerment at other levels. 2. Bottom-up perspective: o This approach originates among the citizens of a community, rather than among its leaders. 3. Contextual differences: o Empowerment is context-specific, and differs across organisations, localities, communities and cultures. 4. Process of empowerment: o It is dynamic and develops overtime. o It is a process of acquiring resources, power, influence or a voice in decision-making. 5. Empowerment develops in a collective context: o Empowerment occurs through linkages with other individuals and through participation in groups and organisations.

classification according to target population of intervention

1. community-wide interventions 2. Milestone interventions 3. High-risk groups interventions

the process of empowerment hinges on two important concepts

1. critical awareness 2. participatory competence

classification according to level of intervention

1. person-centered/ micro-level interventions 2. ecological/ macro-level interventions

benefits and criticisms of prevention-treatment continuum

Benefits: - Encompasses goals of primary, secondary and tertiary approaches. o Takes into account risk reduction and health promotion strategies criticisms: - Developed to categorise physical disorders. o Limited applicability to psychological disorders-origin or cause. o Disease-based prevention models. o Does not take into account socio-political environment and health promotion interventions as part of prevention approach.

Caplan's prevention system

Caplan (1964) added the categories of primary, secondary and tertiary prevention. o Primary: programs and activities designed to reduce the incidence of problems in a population by "counteracting harmful circumstances before they have a chance to reduce illness o Secondary: Reducing the rate of disorders by shortening the duration of existing cases through early diagnosis and effective treatment. o Tertiary: Programs designed to rehabilitate individuals with long term problems to return them to their productive capacity as quickly as possible to their highest potential

Gordon's prevention system

Gordon (1987) made distinctions between the target populations of intervention: o Universal: an entire population. o Indicated: only individuals and groups at high risk. Selected: an individual or subgroup of a population.

primary prevention

This involves activities designed to decrease environmental stressors or to strengthen the individual. o These are aimed at whole populations to reduce potentially harmful circumstances before they can cause psychosocial problems - reduce number of new cases. o Reduce environmental stressors. o To build competencies and strengthen their ability to cope. o Prevent psychological problems from occurring. - For example: social marketing campaigns to address road safety, national drug awareness campaigns.

the wellness enhancement model

is a separate, more inclusive form of intervention. o It is based on the premise that promoting psychological wellness, irrespective of risk factors, can enhance health and protect people against psychological disorders. o This model includes programmes aimed at individuals, families and social and organisational contexts, and embraces the development of healthy lifestyles, social competence and positive self-esteem.

history of prevention programs

• 1960's o Drug prevention programs emerged with a focus on providing information. o Early efforts were based on scare tactics, moralising, and often inaccurate information, and many programs contained fear-arousal messages regarding the social and health consequences of drug use. 1970s - Drug prevention programs began to address personal and social factors that correlate with drug abuse. Affective education became the major preventative approach. - Seligman à "Feel-good" self-esteem vs. "do-good" self-esteem. - "do-good" self-esteem is helpful, "feel-good' self-esteem is not. 1980s - Prevention efforts began to emphasise behavioural strategies. - These programs focused on developing social competency and pro-social coping, subsumed under the rubric of "life-skills". 1990s - Model began to systematically incorporate affective, cognitive and behavioural areas and emphasised development of both skills and pro-social attitudes. - Programs became more comprehensive and broad-based. - Main focus continued to be on eliminating risk. 2000s - Concerns emerged regarding the effectiveness of these programs. - To deal with this concern, several universities and federal agencies have used panels of experts to consider the level of evidence of effectiveness to classify these empirically supported programs. - The highest level of evidence is based on the Chambles and Hollon criteria, which is based on the American Psychological Association Task Force on Psychological Intervention Guidelines. - includes at least two randomised control trials by two independent teams of investigators. The procedures include: - Establishing a set of evaluation standards for selection, - Most often including an experimental design, - Evidence of a statistically significant effect, - Replication of the original study with an experimental design and demonstrated effect, and