Prevention Practices In The 21st Century FM


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Prevention Practices In The 21st Century FM

  1. 1. Prevention and wellness practices in a 21stcentury environment; what we have and what we need January, 2012 Author: Frank G. Magourilos, MPS, CPS, ICPSBig Picture—in the last two decades the science of Behavioral Health Prevention hasadvanced faster than our ability to systemically fund, absorb, and effectively utilize. Wefinally understand through empirical supportive evidence, that in order to prevent andreduce societal ills we must start early and well before the onset of the condition1.Furthermore, we know that to really change the trajectory of any behavior we cannot onlywork on the individual but we must also work to change the environment that the individuallives in23. Given the notion that we have to work within the system of the individual alongwith the system of the environment that also includes society as a whole, this provides theprevention workforce incredible challenges. Clearly prevention, evidence-based,successful prevention, is a very multifaceted ever changing construct which has certaincharacteristics that not only prevention professionals need to understand but it is criticallyimportant that society as a whole, organizations, management, and political leadershipneed to also be aware of.Evidence-based prevention characteristics—the field of prevention is immersed in adisciplinary approach that utilizes many theories and models from many other sciencessuch as; psychology, sociology, public health, and environmental sciences. Because ahuman being and their environment are extremely complex systems45 the need foracademic professional prevention workforce development is paramount; yet the currentglobal prevention workforce system is one that allows individuals to enter the field withnothing higher needed in most cases than a high school diploma. The skills andcompetencies that are needed for today’s prevention professional to be successful aredaunting to say the least. Today’s prevention workforce to be effective needs to be wellversed on concepts, theories, and models such as; risk and protective factors theory6,systems thinking, logic models, geo-political environments, issues, and policies, strategic 1
  2. 2. planning, evaluation, facilitation skills, cultural sensitivity, behavioral models, sociology andcommunity engagement, mental health and abnormal behaviors, drug categories andindividual drug analyses, diffusion of innovation theory7, leadership theories,developmental models and aging, social norms8, media and marketing strategies, genderhealth and prevention, environmental approaches, integration principles, relationshipsbetween substance abuse prevention and injury and violence prevention9.The list can go on but I think my point is made, which glaringly eludes to the tremendouslyextreme disparity between the degree of high, large, positive prevention results that areexpected from the public, managers, departments, politicians, organizations, local andstate governments, versus the reality of having a prevention workforce that is largely andextremely ill prepared, under educated and under funded by hundreds of millions of dollarsjust in New Mexico alone10. Under the current conditions how can we expect populationlevel change prevention results in underage drinking, DWI, drugs, and other risk categorieswhen Prevention funding has decreased by 61% (NM/BHSD/OSAP) in the past two yearsin New Mexico? Furthermore, the average pay of our New Mexico prevention workforce isless than 15 dollars per hour. Most do not have a bachelor’s degree and only one or twohave a degree specific to prevention. If a farmer planted seeds and never watered orcultivated them would he be surprised at the results? It is quite apparent by the impossibleunfunded and under resourced demands put on the current prevention workforce, that ourleaders, funders, local governments, and many others do not understand why we are notgetting the results we all want.Systems thinking; how other systems influence prevention—Systems thinking11 is theprocess by which we attempt to expose the conditions supporting the problem or symptomrather than merely reacting to it. Systems’ thinking considers all the intricately wovenfactors and influences imposed upon the problem, issue, or opportunity and allowexamination of how each relates to the other and interacts as a whole. Rather thanbreaking a problem or opportunity into small pieces and then isolating the pieces in orderto study them, arguably it is more useful to study the entire problem or prospect. In thisway patterns, trends, and systems emerge providing an opportunity to consider both the 2
  3. 3. intentional and unintentional consequences of actions to be taken. It is far easier to getcaught in the reactive trap of addressing symptoms when one is focused on a small partwithout the context of the bigger picture. What is important to understand is thateverything that we do in prevention is positively or negatively influenced by other systemsin our world that we may or more than likely may not have control over. Prevention is asystem, a school is a system, a government is a system, a family is a system, a communityis a system, a city is a system, politics in itself is a system, identified resources is asystem, networking partners is a system, a DWI Planning Council is a system, the Board ofCounty Commissioners is a system, and media is a system, just to name a few. All thesesystems are open, perpetually changing, and interconnected; every time anything ischanged at any one system it affects all the other systems. These relationships need to beunderstood and prevention strategies need to maximize any positive relational influencesthat exist between systems while minimizing negative relational impacts to the extentpossible.Prevention landscape needs a paradigm shift—as mentioned earlier and based onempirical evidence there are many areas we need to work on if we really care to seeindividual and population level change for a better future of our youth, elders, and allmembers of a 21st century society. Below is a list of areas that need our immediateattention:Flavor of the month approaches—we have the tendency of collectively over reacting toany new trend that comes along without strategically thinking the impact funding and otherresources would have by diverting from one area of prevention, such as curbing underageand binge drinking to addressing for example prescription drug abuse; these tendencieshave a huge impact on the overall prevention landscape. A few years ago Meth was ahuge flavor of the month, currently it is prescription drugs, and other trends come and go.Although I am not advocating that these trends not be addressed, my point is that ourprevention strategies have to be largely based on CORE-ROOT CAUSES while utilizingrisk and protective factors theory and other relevant research based principles. Just byplacing a huge amount of our resources on any one single trend we miss the big picture, 3
  4. 4. which are the underlying reasons (individual and environmental) as to why youth andothers are looking to involve themselves in such ill, destructive behaviors in the first place.Coordinated Statewide Prevention—although an argument can be made for having localcommunity level control of prevention programs, the research12 points out that unless thereis a central statewide entity, that may not necessarily control the funding, but rathercoordinates and guides prevention efforts, there will always be the silo effect of individualprograms working in segmented areas without cohesive, and collective system-wideguidance, while always subjected to the mercy of uninformed community politics andindividual agendas. The local needs can always be met by having effective and researchbased on-going community assessments13. A comprehensive needs assessment is thecritical first step a coalition or organization must take in order to develop an effective andsuccessful prevention effort. Furthermore, a comprehensive needs assessment achieveresults because the solutions are targeted at the real causes. By having a coordinatedstatewide prevention effort many benefits would be realized: • Partnerships between programs facilitate the sharing of information, materials, and expertise. • Integrates and maximizes resources. • Facilitates complementary and supplementary programs. • Leads to a system in which the whole is greater than the sum of its parts. • The benefits of coordination are compelling and beneficial to the public. • Increased capacity and improved quality of services to individuals and communities because of shared knowledge and improved planning. • Statewide prevention coordination largely eliminates political agendas, unwarranted interference, and individual power plays at the local level. • If there is to be a systems wide prevention integration approach, federal and state coordination is absolutely critical.Prevention and systems integration—in June of 2011 the Federal Government releasedthe first ever National Prevention Strategy14. The National Prevention Strategy’s vision isworking together to improve the health and quality of life for individuals, families, and 4
  5. 5. communities by moving the nation from a focus on sickness and disease to one based onprevention and wellness. This Strategy envisions a prevention-oriented society where allsectors (systems) recognize the value of health for individuals, families, and society andwork together to achieve better health for all Americans. Aligning and coordinatingprevention efforts across a wide range of partners (systems) is central to the success ofthe National Prevention Strategy. Engaging partners across disciplines, sectors, andinstitutions can change the way communities conceptualize and solve problems, enhanceimplementation of innovative strategies, and improve individual and community well-being.Health and wellness are influenced by the places in which people live, learn, work, andplay. Communities, including homes, schools, public spaces, and work sites, can betransformed to support well-being and make healthy choices easy and affordable. Healthyand safe community environments include those with clean air and water, affordable andsecure housing, sustainable and economically vital neighborhoods (e.g., efficienttransportation, good schools), and supportive structures (e.g., violence free places to beactive, access to affordable healthy foods, streetscapes designed to prevent injury).Healthy and safe community environments are able to detect and respond to both acute(emergency) and chronic (ongoing) threats to health.Making places healthier requires capacity for planning, delivering, and evaluatingprevention efforts. A prevention-oriented society can be supported by integrating healthand health equity criteria into community planning and decision making wheneverappropriate; maintaining a skilled, cross-trained, and diverse prevention workforce;strengthening the capacity of state, tribal, local, and territorial health departments;implementing effective policies and programs that promote health and safety; andenhancing cross-sector data sharing and collaboration. This is the national visionrepresenting 17 heads of departments, agencies, and offices across the Federalgovernment who are committed to promoting prevention and wellness14.Critically important to understand is the significant relationships between interdisciplinaryprevention professionals and all community partners. A wide range of actions contribute toand support prevention, ranging, for example, from a small business that supports 5
  6. 6. evidence-based workplace wellness efforts, to a community-based organization thatprovides job training for the unemployed, to the parent of young children who works toprovide healthy foods and ensure they receive appropriate preventive services. Partnersplay a variety of roles and, at their best, are trusted members of the communities andpopulations they serve. Opportunities for prevention increase when those working inhousing, transportation, education, and many other sectors incorporate health andwellness into their decision making.Professional workforce development—arguably, this is the most important area thatneeds to be addressed and brought forth to individual and community needs of the 21stcentury. Many studies and assessments have been done in this area, and they all pointout the stark inadequacies of the workforce in the field of behavioral health prevention15.Based on previous reports and reviews, barriers to strengthening the behavioral healthprevention workforce can be summarized as: • Inadequate knowledge and expertise of the competencies the workforce needs to meet current and future challenges. • Lack in Identifying, Classifying, and Enumerating the Public Health Prevention Workforce: • Lack of clear, concise, public health prevention profession classification categories. • A lack of a professional workforce education and expertise in advance specialization areas and disciplines such as systems thinking, direct services, environmental strategies, problem id and referral, policy and advocacy, community private sector, public sector, and volunteer sector engagement. • An absence of consistent public health professional credentialing requirements. • Ineffective and inefficient training that mostly includes single-session didactic workshops.More critically, recent findings have exposed that today’s members of the preventionworkforce regularly struggle with the ambiguity of the rules, regulations, standards, andprocedures that manage service delivery, and which sometimes conflict with one another.These rules may also not be grounded in an evidence base. They frequently limitprofessional decisions and judgments, and can severely limit efforts to tailor interventions 6
  7. 7. to individual need. Productivity is reduced because of administrative burdens, most notablythose involving extensive and often repetitive documentation. Members of the workforcehave repeatedly described their low morale and low levels of commitment to theirorganization and to the field because of low pay, the absence of career ladders, excessiveworkloads, tenuous job security, and an inability to influence the organization or system inwhich they are working16171819.Workforce potential solutions—we need to expand the current workforce capacity byutilizing a system or a number of strategies that allow for a very broad-base empiricalprevention knowledge base across multiple disciplines. One way of accomplishing thiswould be to infuse prevention core principles into existing curricula for teachers, doctors,nurses, social workers, psychologists, and other human services professionals. Thiswould allow new professionals entering these fields to be equipped to utilize evidence-based prevention practices into their sphere of influence.There are also numerous prospects for increasing the knowledge base of the existinghuman services workforce. Professional associations of teachers, school administrators,social workers, nurses, doctors, psychologists, child welfare administrators, juvenile justiceadministrators, and the public health field as well, can include information on evidence-based prevention practices within their national conferences and continuing educationtraining courses. Federal agencies may also want to consider issuing workforcedevelopment planning grants for states that are specifically focused on the area ofrevitalizing and intensifying the prevention-based knowledge and competencies of theirworkforce.Cultivate and multiply prevention related partnerships and coalitions—a critical partof workforce development and expansion needs to come from outside the normalboundaries of the behavioral health field. There are simply not sufficient financial andhuman resources to address such a complex problem as adverse human behaviors andthe environmental factors involved by simply doing what the current prevention field hasbeen doing; namely a small number of individuals attempting to prevent millions of youth 7
  8. 8. and adults from risky behaviors while at the same time trying to stem the environmentaltides of risk factors such as poverty, media, music, Internet, and motion picture glorificationof alcohol, selfishness, and social permissiveness just to name a few. Having said this,the solution is imbedded in the simple premise that health and wellness, includingbehavioral health, is in the best interest of everyone and every sector of our socialenvironment. Promoting prevention and wellness initiatives are attractive because theyimpact all aspects of societal functioning. For example, the case can be made thatbusinesses should play a vital role in prevention and wellness because it would greatlyinfluence their bottom line. Healthy and productive young people are a coveted resourcefor today’s competitive world. Adults with children that have health insurance with theiremployers would arguably have lower healthcare costs thus, reducing the premiums thathave to be paid by businesses. These are just a few examples of cost savings andincentives for businesses to participate, support, advocate, and even partially fundprevention and wellness. The same can be said for many other sectors in ourcommunities (systems); coalitions, clubs, civic organizations, public, private, non-profits,volunteer, etc. need to be on the table, and a very specific targeted, sustainable effortneeds to take place to bring everyone on-board to infuse prevention and wellness into theentire social environment.Leadership—however, in order for such a wide net to be systematically and successfullydispersed there has to be critical leadership and coordination from federal, state, and localgovernmental agencies. The Affordable Care Act enacted in 2010 authorized the creationof the National Prevention, Health Promotion, and Public Health Council, a body chargedwith providing coordination and leadership at the federal level among executivedepartments and agencies in relation to prevention, wellness, and health promotion20; thisNational Prevention Council would be the logical place for providing leadership andcoordination in addressing the need for total community engagement, and in fact theNational prevention Strategy released in June of 2011and created by this Council calls forjust that. In addition, we will need to look at existing data systems that can be expanded toinclude specific community sectors for process and outcome measures. There will also bethe need to look at available or create new evidence based programs and practices that 8
  9. 9. are tailored to each community and business segment. Finally, we will have to look atcreating, improving existing and/or developing a segment of our prevention workforce thatwould specialize in wide and far reaching relationship building and partner engagementfrom all community sectors.Another critical area that leadership has to be involved in is the prerequisite to have amuch focused mission and consistent strategy in the robust dissemination of preventionresearch findings. From how prevention impacts human developmental stages and whatstrategies are effective, to how systems and environmental interactions support or hinderquality of life. Furthermore, prevention integration models that include cost and benefitsanalyses need to be created and disseminated into the many different verbiage andlanguages of business sectors and other organizational environments. To apply itdifferently, prevention principles, practices, and core foundations will be disseminateduniversally, however additional components such as how these principles, practices, andpolicies will impact a particular sector of the economy or the social environment should bedisseminated to be understood by using the lingo of such sector it is intended for.Resources—if there is fruition in the creation and implementation of a coordinatedsustainable prevention and wellness integration into every core and every component of allthe sectors that make up the systems that function as our social environments, then theadditional saved resources from lower health care and societal costs, along with the qualityof life improvements gained, will exponentially eclipse the resources needed to realize,implement, and sustain this prevention integration systems approach.Conclusion—clearly if we want to take advantage of the research and the recentadvances in prevention and wellness we have to also work on the implementation andworkforce development side of the equation. The logical place for the spark needed tolead us into this direction is the National Prevention Council and the Substance Abuse andMental Health Services Administration, SAMHSA that has prevention as its top priority21,their combined leadership would put the nation in a great position to advance preventionservices in all sectors of our social environment. Furthermore, the 2009 Institute of 9
  10. 10. Medicine, IOM report27 along with the National Prevention Strategy provide thefoundational 21st century prevention and wellness roadmap to follow. Currently theinfrastructure necessary to broadly and expansively deliver prevention services is notcollectively been constructed, although most pieces already exist. It is time for a paradigmshift in prevention and wellness, and the tipping point is within reach waiting for leadershipto strike the match.References1. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities Gruenewald, P.J. “Commentary – From the ecological to the individual and back again,” Addiction, 99:1249-1250, 2004.3. Halprin-Felscher, B. and Biehl, M. "Developmental and environmental influences on underage drinking: A general overview." In R. Bonnie and M.E. OConnell (eds.) Reducing Underage Drinking: A Collective Responsibility, Background Papers [CD- ROM]. Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press, 2004.4. Hartmut, Bossel, Systems and Models; Complexity, Dynamics, Evolution, Sustainability. Norderstedt, Germany; Books on Demand, 2007.5. Meadows, Donella, H., Thinking in Systems; A Primer; Chelsea Green Publishing, 2008.6. Hawkins, J.D.; Catalano, R.F.; Kosterman, R.; Abbott, R.; and Hill, K.G. Preventing adolescent health-risk behaviors by strengthening protection during childhood. Archives of Pediatric and Adolescent Medicine 153:226–234, 1999.7. Rogers, Everett M. (1983). Diffusion of Innovations. New York: Free Press. ISBN 978-0-02-926650-2.8. Perkins, H. W. & Craig, D. A. (2003). "The Hobart and William Smith Colleges experiment: A synergistic social norms approach using print, electronic media and curriculum infusion to reduce collegiate problem drinking". In H. W. Perkins (Ed.), The Social Norms Approach to preventing school and college age substance abuse: A 10
  11. 11. handbook for educators, counselors, clinicians (Chapter 3). San Francisco: Jossey- Bass.9. Hoaken, P. N. S., & Stewart, S. H. (2003). Drugs of abuse and the elicitation of human aggressive behavior. Addictive Behaviors, 28, 1533-1554.10. EXECUTIVE SUMMARY Behavioral Health Needs & Gaps In New Mexico, Page xxvi, Gerald M. Weinberg (2001 - revised) An Introduction to General Systems Thinking. Dorset House ISBN 0-932-63349-8.12. Implementing Science Based Prevention; The Experiences of Eighteen Communities and Progress Towards Inter-Agency Coordination to Reduce Alcohol and Substance Abuse Among Adolescents Evaluation Report for the Washington State Incentive Grant (July 1998 – July 2002), Fagan, A.A., Hawkins, J.D., Catalano, R.F. (2008). Using community epidemiologic data to improve social settings: The Communities That Care prevention system. In M. Shin (Ed.) Toward positive youth development: Transforming schools and community programs (pp. 292–312). Oxford; New York: Oxford University Press.14. The National Prevention Strategy: America’s Plan for Better Health and Wellness, HHS, 2011, Annapolis Coalition. (2007). An action plan for behavioral health workforce development: A framework for discussion. Substance Abuse and Mental Health Administration. Shortage Designation: HPSAs, MUAs & MUPs. Retried on December 5, 2008 from Institute of Medicine. (2000). To err is human: Building a safer health system (L. T. Kohn, J. M. Corrigan, & M. S. Donaldson, Eds.). Washington, DC: National Academy Press.17. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.18. Institute of Medicine. (2003). Health professions education: A bridge to quality (A. C. Greiner & E. Knebel, Eds.). Washington, DC: The National Academies Press. 11
  12. 12. 19. Blankertz & Robinson, 1997b; Center for Health Workforce Studies, 2006; Gellis & Kim, 2004; Hanrahan & Gerolamo, 2004; IOM, 2003, 2004; Zurn, Dal Poz, Stilwell, & Adams, 2004.20. The affordable Care Act 2010, overview21. SAMHSA’s Eight Strategic Initiatives, the AuthorFrank G. Magourilos is a Sr. Certified Prevention Specialist with a Master’s Degree inPrevention Science from Oklahoma University and Bachelor’s Degrees in CognitiveBehavioral Psychology and Intercultural Communication from the University of NewMexico. He is the Executive Director of the New Mexico Credentialing Board forBehavioral Health Professionals, and he is also the Founder of theNew Mexico Prevention Network, Additionally, Mr.Magourilos oversees all the Prevention Programming for the Santa Fe County DWIProgram and is a Technical Prevention Advisor for the New Mexico Department of Finance& Administration Local DWI Programs. 12