Amer. 1. Orthopsychiat. 46(3), July 1976
A N INSTRUMENT FOR DIFFERENTIATING PROGRAMS IN PREVENTION-PRIMARY, SECONDARY AND TERTIARY Felice D. Perlmutter, Ph.D., Andrea M. Vayda, M.A., Paul K. Woodburn, M.S.W. School of Social Administration, Temple University, Philadelphia
Prevention programs in mental health have been developed slowly, in part due to an inadequate understanding of primary, secondary, and tertiary prevention. This paper describes an instrument developed to identify critical dimensions to consider in diflerentiating among prevention programs, and to help clarify the complex issues underlying the design of such programs.
revention programs became a key area of interest within the field of mental health during the 1960s. The growing body of literature that deals with prevention has, to a large extent, been oriented toward developing theoretical and conceptual frameworks for prevention activity,'! exploring the implications of different perspectives of mental illness for prevention,13 or discussing various techniques appropriate to a preventive approach.'** l9 These factors and the history of interest in this area have been summarized else-
P
l3
A basic theme in the prevention literature is that the nature of prevention
is inadequately understood by practitioners in the field and that, despite legislative intent, prevention has not become a major component of mental health programs.l67 In an effort to explain the relative dearth of prevention activity, Broskowski and Baker synthesized previous work in this area and derived four barriers to primary prevention: 1) conflicts inherent in the definition of prevention levels; 2 ) the broad-based social system change indicated in prevention goals; 3) difficulties in demonstrating the rationale, effectiveness, arid impact of prevention; and 4 ) lack of public interest in preventive venture^.^ These barriers stem largely from an external, or
Submitted to the Journal in October 1975.
533
534
DIFFERENTIATING PREVENTION PROGRAMS
macro, view of the predicament of prevention activity; the questions raised with regard to conceptual underpinnings, practicality, and political viability of prevention are important for both policy makers and practitioners to understand, if prevention is going to be promoted as a full-fledged mental health priority. Another vantage point on barriers to prevention focuses on forces internal to the operation of mental health programs. This perspective is exemplified by questions raised in two areas: 1 ) whether mental health professionals necessarily have the skills (training and expertise) to develop prevention programs; l o ,l‘ and 2 ) whether expertise exists in the area of research and evaluation in primary prevention.”, 21 It should be noted, however, that this interest in prevention is not an altogether new phenomenon; it has its roots in the origin of the mental health movement in the United States. As early as 1908 the need for “broad-gauge programs for prevention” was recognized by the National Committee for Mental Hygiene, but was not imp1emented.O Given the current legislative and professional mandate, there exists in the 1970s an opportunity that must not be lost for lack of professional expertise or initiative. All efforts must be made to develop broadgauge programs for prevention. This paper has two objectives. The first is to describe the design of an instrument that differentiates among programs in primary, secondary, and tertiary prevention. The instrument has two potential uses: 1) to stimulate professionals
to develop prevention programs, using the items on this instrument as illustrations of the different prevention levels; and 2) to clarify which level of prevention is likely to be supported or rejected in the field depending upon the socialprofessional-political context of the community mental health center. The second objective concerns more theoretical concepts, and involves delineation of the critical dimensions underlying each program, based on the results of the validation process. BACKGROUND
This paper reports on one aspect of a study designed to examine prevention programs in community mental health centers in Region III.* This research was a response to the 1963 legislation which mandated that the consultation-education service be directly linked to “the public health arena of prevention of illness and promotion of health.” l4 The study is designed to obtain information concerning the present programs of prevention in the consultation and evaluation units of CMHCs and to contribute to the understanding of prevention in the field of mental health. One of the research questions was designed to elicit information concerning which types of prevention programs are likely to be supported or rejected by centers, as perceived by center administrators and consultation-evaluation practitioners in the field. Specifically, do primary prevention programs receive as great an acceptance as do programs in secondary and tertiary prevention?
*This study is supported by the National Institute of Mental Health, MH-25351, Prevention Programs in Community Mental Health Centers. All CMHCs in Delaware, Maryland, Pennsylvania, Virginia, West Virginia, and Washington, D.C., federally funded prior to July 1973, compose the population of this study.
PERLMUTTER, VAYDA AND WOODBURN
535
In the process of designing instru- came the basis of the instrument unments to explore the perceptions of ad- der discussion. * ministrators and front-line practitioners toward prevention, it became apparent METHOD that an open-ended approach was rife The problems addressed were those of with hazards. Pretests in the field showed item construction and construct validatwo areas of methodological concern. tion. First, the thinking about prevention and Item Construction the three levels of prevention-primary, secondary, and tertiary-was laden with Two considerations were taken into preconceptions, even when the standard account in compiling the list of prodefinitions of these levels were provided. grams. First, the programs must fall The variable frames of reference con- equally into primary, secondary, and jured up by these levels in terms of tertiary prevention categories. Caplan’s goals, scope of programs, and target definitions were used as the basis for population made it difficult to ascertain distinguishing among the prevention levthe respondent’s biases and assumptions, els: and therefore impossible to generalize Primary prevention aims at reducing the infrom the data. cidence of new cases of mental disorder in the A second difficulty was that a dis- population by combating harmful forces which crepancy often existed between the re- operate in the community and by strengthensponse to a conceptual definition of a ing the capacity of people to withstand stress. program and the response to the pro- Secondary prevention aims at reducing the gram in operation. Thus, hesitant or duration of cases of mental disorder which occur in spite of the programs of primary prenegative responses were sometimes elic- vention. By shortening the duration of existited with respect to a particular level of ing cases, the prevalence of mental disorder in prevention (primary, secondary, terti- the community is reduced. . . . ary) on a theoretical level, while there Tertiary prevention aims at reducing the comwas positive response to specific pro- munity rate of residual defect which is a seto mental disorder. It seeks to ensure grams falling under that same level of quel that people who have recovered from mental prevention. disorder will be hampered as little iis possible The decision was therefore made to by their past difficulties in returning to full develop a list of thirty specific pro- participation in the occupational and social grams in order to obtain information life of the community. about resistance to, or support of, preA second consideration dealt with the vention activity. This list enabled us to description of the programs. .4pplying have a common frame of reference for the definition of primary, secondary, and the discussion of prevention activity as tertiary prevention, as cited above, the well as to begin to specify across cen- description of each program incorpoters the particular loci of support or rated variations on three dimensions: resistance to prevention. This list be- 1) target group, 2) technique, and 3 )
* Shirley Heinemann, M.S., deceased, the original Project Director, played an important role in the design of this instrument and in the early stages of the research design.
DIFFERENTIATING PREVENTION PROGRAMS
536
goals of the program. The target group was defined as the participants in the program (ie., the individual, group or agency being worked with directly by center staff.) The techniques were defined as those procedures commonly employed by staff (e.g., consultation, training, education, community organization, life crisis intervention, or treatment). The goals were defined as a program’s objectives (e.g., more effective parent performance, clergy counseling). The instrument consists of thirty randomly arranged items, ten in each level. For purposes of clarity, the items are presented here according to their prevention level classification and not in the random arrangement used in the instrument. PROGRAMS IN PRIMARY PREVENTION
PROGRAMS IN SECONDARY PREVENTION
1. A follow-up of all callers to the center who
were given an initial appointment for treatment and failed to keep the appointment. 2. A twenty-four hour emergency home-visiting team. 3. A program at a school for blind children to offer first-aid to children who appear emotionally upset. 4. A round-the-clock consultation service for general practitioners in the catchment area who have individual cases with emotional problems. 5 . A training program for local police in handling persons with symptoms of emotional disorder. 6. An open-house at the center with tours and presentations in order to inform catchmentarea residents about treatment services available. 7. A program for management-level personnel at local industries about symptom recognition and referral techniques. 8. A training program for nurses at a local general hospital about methods .of identifying symptoms of emotional disorder among their patients. 9. A teenage PAL program for elementary school children who receive treatment from the center. 10. Counseling services for mothers experiencing post-partum depression.
1. A program of group sessions for parents of new-born mentally retarded children working around the areas of parental anxiety and guilt. 2. Providing consultation to a marriage counseling service based in a local church. 3. A program training ex-gang members to become gang workers. 4. A crisis intervention program for rape victims based in emergency rooms of local hospitals. 5. Organizing a tenant’s rights group at a catchment area’s housing project. 6. Working with PTAS of the local schools developing drug abuse prevention programs.
1. A program for center staff to acquaint them with the range of resocialization services available in the community for discharged inpatients.
7. Developing and staffing a prenatal care program for unwed adolescents.
2. A Saturday night social program for adult mentally retarded clients of the center.
8. A program with local primary school teachers to sensitize them to the problems of the single parent family.
3. A program of vocational and aptitude test-
9. Offering discussion groups for men and women coping with issues raised by the women’s liberation movement.
10. A program offering consultation to private nursing homes on ways to enrich the social experience of patients.
PROGRAMS IN TERTIARY PREVENTION
ing for all newly-released outpatients with appropriate referrals for training and job placement. 4. A program to escort patients discharged
from the in-patient unit to their first appointment for after-care. 5. A training program for paraprofessional staff of mental hospitals to enable them to
PERLMUTTER, VAYDA AND WOODBURN
537
vention for each of the thirty items according to Caplan’s definitions.s The reputational method of selection of experts was used, as panel membt:rs were identified by NIMH staff at the regional and national levels on the basis of their professional interests, activity, and publications on prevention. The panel consisted of a former president of the American Orthopsychiatric Association, seven academicians (including deans, chairmen of departments of psychiatry, professors in community psychiatry, education and psychiatry), two planners in community mental health servkes, and one NIMH staff member.* Validity was established if agreement Construct Validity among the judges was statistically sigThe major technical problem in the nificant at the .05 level (Binomial design of this instrument was one of Test) * O on each item of the instrument. construct validity: do the program items Thus the validation was item ‘by item, comprising the instrument in fact repre- allowing for the rejection of any nonsent their assigned prevention level? T o validated program using the above statest for validity, the following three- tistical criterion. stage procedure was used. Stage I consisted of the three mem- FINDINGS AND DISCUSSION Twenty-eight (93%) of the 30 items bers of the research team independently classifying forty program items in terms had agreement significant at the .05 of the level of prevention. The items level. TABLE1 presents the results by were retained only when there was con- prevention level, specifying the number sensus among the members; ten items of expert agreements and the significance were dropped because of lack of agree- level for each number of agreements. Six ment. or more agreements are statistically sigIn Stage ZI the list of agreements was nificant. submitted to an NIMH staff consultant When the three prevention levels are for his classification. The instrument was taken into account, we find little variadeveloped as a result of a combined con- tion between secondary and terl iary levsensus between the consultant (Stephen els-for these levels the extent of agreeE. Goldston, Ed.D., M.S.P.H.) and the ment among the experts is significant for research team. all the programs. The primary prevenIn Stage IZZ a panel of ten experts tion category, however, has the greatwas asked to specify the level of pre- est dispersion on number of agree-
reach patients self care, homemaking, and budgeting. 6. A program working with boarding home proprietors on the problems of after-care patients housed in these homes. 7. A short term homemaker service to assist mothers discharged from the in-patient service. 8. A program for halfway house residents to familiarize them with local transportation syst e m and local shopping facilities. 9. A “clerical service” for universities and businesses performed by hospitalized mental patients to provide them with income, and job experience. 10. A program for families of discharged patients about the needed supportive role of the transition period.
* An eleventh expert declined to participate because he felt the items were not sufficiently delineated (to be discussed in greater detail in the final section on critical dimensions).
DIFFERENTIATING PREVENTION PROGRAMS
Table I FREQUENCY DISTRIBUTION OF PROGRAMS BY NUMBER OF EXPERTS IN AGREEMENT AND BY PREVENTION LEVEL AGREEMENTS PROGRAMS 10 9 8
PRIMARY 2 2 3
6
I I
r
5 4
3 2
SECONDARY I .I
TERTIARY I
.wo .ooo
2 5 I
2 4 2
.003 .OI5 .05 I
-
.I34
-
I -
ments and is also the type of program that receives the greatest amount of agreement. Eight or more experts agree on the prevention level of 70% of the primary type programs (see TABLE 1). This is of interest particularly because primary prevention programs are the most controversial, and the crux of discussions about prevention often addresses the ambiguity of the programs to be developed. A major assignment of this exploratory research is to attempt to specify the issues or difficulties underlying the relationship between the conceptual and operational definitions of prevention programs. A reexamination of the primary prevention programs that were not validated show two thorny factors which have a potential confounding impact on the identification of a program as primary prevention. One factor is the borderline symptomology of the problem at hand; the other factor is the degree to which the target of the intervention can be associated with a therapeutic function. The two items that were not validated
-
-
-
I
-
P
-
.235
are in the primary prevention category : “a crisis oriented intervention program for rape victims based in emergency rooms of local hospitals;” and “a program offering consultation to private nursing homes on ways to enrich the social experience of patients.” Borderline symptomology appears to be a major point of difficulty in the categorization of primary prevention programs. By definition primary prevention is geared toward intervention prior to, or independent of, the development of symptoms of emotional disorder in a high risk population. In the case of the program for rape victims, the alternate prevention level for all disagreements was secondary prevention, indicating the respondents assumed the existence of emotional symptoms. Given a program that is offered to all rape victims regardless of any specific individual request for psychotherapeutic intervention or of the onset of emotional symptoms, a decision must be made whether a rape victim is “high risk” (and hence an appropriate response is a primary prevention activity)
PERLMUTTER, VAYDA AND W O O D B U R N
or whether emotional symptoms are inevitable and necessarily require therapeutic help.* In regard to the nursing home item, the modal designation was tertiary prevention ( N = 5 ) . The confusion of this item was undoubtedly due to the beneficiary group being designated as nursing home patients, rather than residents. The terminology creates ambiguity because primary prevention programs are generally not directed at persons or groups defined as “patients.” This demonstrates the urgency of accurate word usage, since it was the research team’s intention in this item to view nursing home residents as a “group at risk” (not as patients with psychiatric problems) ; consequently, the program was intended to promote mental health. These two items demonstrate the subtle and complex dimension in differentitating between primary and secondary strategies. Similar decisions must be made with respect to various life crises, such as divorce, illness, and death, among others. A second major point of difficulty identified by closer examination of the program descriptions is that the nature of the target population can play a preeminent role in the classification process. In those primary level programs that have the highest agreement, the target group was identified in terms of a clear-cut occupational or organizational affiliation not associated with a therapeutic function ( e . g . , PTA, teachers, ten-
539
ants). As the extent of agreement decreased, however, the primary level programs revolved around a target population identified via symptom-linked characteristics: (e.g., unwed adolescents, marriage counselors, parents of crippled children). Looking at the secondary level programs with the highest amount of disagreement, we find a similar situation in that all disagreements are classified as primary. For these secondary programs, the target population is identified in occupational terms which can generally be viewed as independent of emotional disorder (e.g., general practitioners, managers in industry, police) .z CRITICAL DIMENSIONS
In order to address the complexities in characterizing the dimensions of the program items, the three specijied by the study team will be recalled: target group, technique, and goals of the program. In addition to elaborating on target group and goals, several other dimensions must be discussed, including beneficiary of the program and organizational domain. In regard to target groups, it was emphasized that the target of the. intervention must be clearly specified for this is a central indicator of the level of the prevention activity. Furthermore, the target group must be differentiated from the beneficiary of the program, a dimension that must be added. For example, the fifth program item in the tertiary prevention grouping is a “training program for paraprofessional staff of mental hos-
* The following criteria, defined in our NIMH proposal, were suggestive of our thinking about what constitutes primary prevention and served as the basis for designing the research instruments. Primary prevention activities constitute those activities that are: 1 ) directed at persons or groups nor defined as patients; 2) directed usually at groups-at-risk; 3 ) concerned with contextual rather than individual functioning (e.g., schools, boarding homes, etc., ils systems); and 4) designed to maintain healthy functioning rather than meliorate pathology (e.g., well baby clinics, vocational counseling, etc.) .
540
DIFFERENTIATING PREVENTION PROGRAMS
pitals to enable them to teach patients self care, homemaking and budgeting.” The target of the intervention in this instance is the paraprofessional staff, but the beneficiaries of the program are the patients. The target group for participation in the program is not necessarily the beneficiary for preventive impact. What is critical here to the classification process is the prevention level achieved for the beneficiary, not the target group, of the program. Furthermore, the target group, if different from the beneficiary, may also be gaining primary or secondary level impact as an indirect effect of the ~ r o g r a m . ~ The “goal” dimension is elaborated upon by the consultants as they identify the reality of overlapping goals and multiple functions (both manifest and latent) of prevention programs. Several of the respondents addressed the difficulty in making the classification decision since they were asked to classify the program in only one prevention category. Realistically, however, prevention programs will have more than one kind of preventive impact:
.
. . in practice primary, secondary and tertiary elements overlap, and a decision on which element predominates depends in considerable degree on the ideas of the program directors and their staff regarding their mission as well as what turns out to be feasible in any particular situation.? Consequently the importance of the unique social-professional-political context of each program must be examined and understood as a crucial factor in defining the goals appropriate to the different levels of prevention activity. And, finally, the specification of the organization’s domain provides an essential dimension, as noted in the above discussion of the findings. This supports
the argument that institutions concerned with promoting mental health (e.g., recreation programs, schools, churches) would fall mainly into the primary rubric; institutions serving people with occasional emotional support (e.g., hospitals, social agencies, juvenile courts) would fall mainly into the secondary r ~ b r i c The . ~ manifest and latent functions of the institutions must be considered and made explicit in classifying and planning for prevention programs. CONCLUSIONS
Although the development of the instrument described in this paper is in its early stages, it is the hope of the research team that this discussion has clarified some of the definitional issues surrounding prevention programs, as well as identified new issues. While we recognize that in reality the different prevention levels operate on a continuum, the paper has addressed the issues separately only for the purpose of conceptual clarification. Hopefully this paper will stimulate other professionals to take the initiative in formulating and implementing new programs as well as in further refining this instrument and developing other tools that can aid in the clarification of the theoretical issues concerning the prevention of mental illness and the promotion of mental health. REFERENCES E. 1963, Primary prevention of mental and emotional disorders: a conceptual framework and action possibilities. Amer. I. Orthopsychiat. 33:832-847. 2. BOWER, E. 1972. KISS and kids: a mandate for prevention. Amer. J. Orthopsychiat. 42:556-565. 3. BOWER, E. 1974. Personal communication. 4. BROSKOWSKI, A. 1974. Personal communication.
I.
BOWER,
PERLMUTTER, VAYDA AND WOODBURN 5 . BROSKOWSKI, A. AND BAKER, F. 1974. Professional, organization and social barriers to primary prevention. Amer. J. Orthopsychiat. 44:707-7 19. 6. CAPLAN, 0. 1964. Principles of Preventive Psychiatry. Basic Books, New York. 7. CAPLAN, G. 1974. Personal communica-
tion. B.CAPLAN, 0. 1974. Support Systems and Community Mental Health: Lectures on Concept Development. Behavioral Publications, New York. (pp. 189-190) 9. COWEN, E., GARDNER, E. AND ZAX, M. 1967. Emergent Approaches to Mental Health Problems. Appleton-Century-Crofts, New York. 10. GLASSCOTE, R. AND GUDEMAN, J . 1969. The Staff of the Mental Health Center: A Field Study. Joint Information Service of APA and NAMH, Washington, D.C. 1 1 . COLDSTON, s. The Route to Primary Prevention Reconsidered: A Rebuttal. N.I.M.H., Division of Special Mental Health Programs, Washington, D.C. (mimeograph) 12. KESSLER, M. AND ALBEE, G. 1975. Primary prevention. Ann. Rev. Psychol. 26: 557591. 13. MECHANIC, D. 1969. Mental Health and So-
541
cial Policy. Prentice-Hall, Englewood Cliffs, N.J. 14. National Institute of Mental Health. 1966. Consultation and Education: A Service of the Community Mental Health Center. NIMH, Washington, D.C. 15. PERLMUTTER, F. AND SILVERMAN, H. 1973. Conflict in C and E. Comm. Ment. Hlth J. 9: 116-122. 16. PERLMUTTER, F . AND SILVERMAlr, H. 1972. The Community Mental Health Center: a structural anachronism. SOC. Wk 17:7884. 17. REIFF, R. 1967. Mental health manpower and institutional change. I n Emcrgent Approaches to Mental Health Problems, E. Cowen et al, eds. Appleton-Century-Crofts, New York. 18. ROWLAND, L. 1969. Let’s try prevention. I n Distress in the City, W. Ryan, ed. Case Western Reserve University, Cleveland. I ~ . R Y A N ,w . , ed. 1969. Distress in the City. Case Western Reserve University, Cleveland. 2 0 . SIEGAL, s. 1956. Nonparametric Statistics, McGraw Hill, New York. (pp. 36-42) 21.VANANTWERP, M. 1971. The route to primary prevention. Comm. Ment. Hlth J. 7:183-188.
For reprints: Dr. Felice Perlmutter, Principal Investigator, Professor, School of Social Administration, Temple University, Ritter Addition (5th Floor), 13th and Columbia Avenue, Philadelphia, Pa. 19122
A N INSTRUMENT FOR DIFFERENTIATING PROGRAMS IN PREVENTION-PRIMARY, SECONDARY AND TERTIARY Felice D. Perlmutter, Ph.D., Andrea M. Vayda, M.A., Paul K. Woodburn, M.S.W. School of Social Administration, Temple University, Philadelphia
Prevention programs in mental health have been developed slowly, in part due to an inadequate understanding of primary, secondary, and tertiary prevention. This paper describes an instrument developed to identify critical dimensions to consider in diflerentiating among prevention programs, and to help clarify the complex issues underlying the design of such programs.
revention programs became a key area of interest within the field of mental health during the 1960s. The growing body of literature that deals with prevention has, to a large extent, been oriented toward developing theoretical and conceptual frameworks for prevention activity,'! exploring the implications of different perspectives of mental illness for prevention,13 or discussing various techniques appropriate to a preventive approach.'** l9 These factors and the history of interest in this area have been summarized else-
P
l3
A basic theme in the prevention literature is that the nature of prevention
is inadequately understood by practitioners in the field and that, despite legislative intent, prevention has not become a major component of mental health programs.l67 In an effort to explain the relative dearth of prevention activity, Broskowski and Baker synthesized previous work in this area and derived four barriers to primary prevention: 1) conflicts inherent in the definition of prevention levels; 2 ) the broad-based social system change indicated in prevention goals; 3) difficulties in demonstrating the rationale, effectiveness, arid impact of prevention; and 4 ) lack of public interest in preventive venture^.^ These barriers stem largely from an external, or
Submitted to the Journal in October 1975.
533
534
DIFFERENTIATING PREVENTION PROGRAMS
macro, view of the predicament of prevention activity; the questions raised with regard to conceptual underpinnings, practicality, and political viability of prevention are important for both policy makers and practitioners to understand, if prevention is going to be promoted as a full-fledged mental health priority. Another vantage point on barriers to prevention focuses on forces internal to the operation of mental health programs. This perspective is exemplified by questions raised in two areas: 1 ) whether mental health professionals necessarily have the skills (training and expertise) to develop prevention programs; l o ,l‘ and 2 ) whether expertise exists in the area of research and evaluation in primary prevention.”, 21 It should be noted, however, that this interest in prevention is not an altogether new phenomenon; it has its roots in the origin of the mental health movement in the United States. As early as 1908 the need for “broad-gauge programs for prevention” was recognized by the National Committee for Mental Hygiene, but was not imp1emented.O Given the current legislative and professional mandate, there exists in the 1970s an opportunity that must not be lost for lack of professional expertise or initiative. All efforts must be made to develop broadgauge programs for prevention. This paper has two objectives. The first is to describe the design of an instrument that differentiates among programs in primary, secondary, and tertiary prevention. The instrument has two potential uses: 1) to stimulate professionals
to develop prevention programs, using the items on this instrument as illustrations of the different prevention levels; and 2) to clarify which level of prevention is likely to be supported or rejected in the field depending upon the socialprofessional-political context of the community mental health center. The second objective concerns more theoretical concepts, and involves delineation of the critical dimensions underlying each program, based on the results of the validation process. BACKGROUND
This paper reports on one aspect of a study designed to examine prevention programs in community mental health centers in Region III.* This research was a response to the 1963 legislation which mandated that the consultation-education service be directly linked to “the public health arena of prevention of illness and promotion of health.” l4 The study is designed to obtain information concerning the present programs of prevention in the consultation and evaluation units of CMHCs and to contribute to the understanding of prevention in the field of mental health. One of the research questions was designed to elicit information concerning which types of prevention programs are likely to be supported or rejected by centers, as perceived by center administrators and consultation-evaluation practitioners in the field. Specifically, do primary prevention programs receive as great an acceptance as do programs in secondary and tertiary prevention?
*This study is supported by the National Institute of Mental Health, MH-25351, Prevention Programs in Community Mental Health Centers. All CMHCs in Delaware, Maryland, Pennsylvania, Virginia, West Virginia, and Washington, D.C., federally funded prior to July 1973, compose the population of this study.
PERLMUTTER, VAYDA AND WOODBURN
535
In the process of designing instru- came the basis of the instrument unments to explore the perceptions of ad- der discussion. * ministrators and front-line practitioners toward prevention, it became apparent METHOD that an open-ended approach was rife The problems addressed were those of with hazards. Pretests in the field showed item construction and construct validatwo areas of methodological concern. tion. First, the thinking about prevention and Item Construction the three levels of prevention-primary, secondary, and tertiary-was laden with Two considerations were taken into preconceptions, even when the standard account in compiling the list of prodefinitions of these levels were provided. grams. First, the programs must fall The variable frames of reference con- equally into primary, secondary, and jured up by these levels in terms of tertiary prevention categories. Caplan’s goals, scope of programs, and target definitions were used as the basis for population made it difficult to ascertain distinguishing among the prevention levthe respondent’s biases and assumptions, els: and therefore impossible to generalize Primary prevention aims at reducing the infrom the data. cidence of new cases of mental disorder in the A second difficulty was that a dis- population by combating harmful forces which crepancy often existed between the re- operate in the community and by strengthensponse to a conceptual definition of a ing the capacity of people to withstand stress. program and the response to the pro- Secondary prevention aims at reducing the gram in operation. Thus, hesitant or duration of cases of mental disorder which occur in spite of the programs of primary prenegative responses were sometimes elic- vention. By shortening the duration of existited with respect to a particular level of ing cases, the prevalence of mental disorder in prevention (primary, secondary, terti- the community is reduced. . . . ary) on a theoretical level, while there Tertiary prevention aims at reducing the comwas positive response to specific pro- munity rate of residual defect which is a seto mental disorder. It seeks to ensure grams falling under that same level of quel that people who have recovered from mental prevention. disorder will be hampered as little iis possible The decision was therefore made to by their past difficulties in returning to full develop a list of thirty specific pro- participation in the occupational and social grams in order to obtain information life of the community. about resistance to, or support of, preA second consideration dealt with the vention activity. This list enabled us to description of the programs. .4pplying have a common frame of reference for the definition of primary, secondary, and the discussion of prevention activity as tertiary prevention, as cited above, the well as to begin to specify across cen- description of each program incorpoters the particular loci of support or rated variations on three dimensions: resistance to prevention. This list be- 1) target group, 2) technique, and 3 )
* Shirley Heinemann, M.S., deceased, the original Project Director, played an important role in the design of this instrument and in the early stages of the research design.
DIFFERENTIATING PREVENTION PROGRAMS
536
goals of the program. The target group was defined as the participants in the program (ie., the individual, group or agency being worked with directly by center staff.) The techniques were defined as those procedures commonly employed by staff (e.g., consultation, training, education, community organization, life crisis intervention, or treatment). The goals were defined as a program’s objectives (e.g., more effective parent performance, clergy counseling). The instrument consists of thirty randomly arranged items, ten in each level. For purposes of clarity, the items are presented here according to their prevention level classification and not in the random arrangement used in the instrument. PROGRAMS IN PRIMARY PREVENTION
PROGRAMS IN SECONDARY PREVENTION
1. A follow-up of all callers to the center who
were given an initial appointment for treatment and failed to keep the appointment. 2. A twenty-four hour emergency home-visiting team. 3. A program at a school for blind children to offer first-aid to children who appear emotionally upset. 4. A round-the-clock consultation service for general practitioners in the catchment area who have individual cases with emotional problems. 5 . A training program for local police in handling persons with symptoms of emotional disorder. 6. An open-house at the center with tours and presentations in order to inform catchmentarea residents about treatment services available. 7. A program for management-level personnel at local industries about symptom recognition and referral techniques. 8. A training program for nurses at a local general hospital about methods .of identifying symptoms of emotional disorder among their patients. 9. A teenage PAL program for elementary school children who receive treatment from the center. 10. Counseling services for mothers experiencing post-partum depression.
1. A program of group sessions for parents of new-born mentally retarded children working around the areas of parental anxiety and guilt. 2. Providing consultation to a marriage counseling service based in a local church. 3. A program training ex-gang members to become gang workers. 4. A crisis intervention program for rape victims based in emergency rooms of local hospitals. 5. Organizing a tenant’s rights group at a catchment area’s housing project. 6. Working with PTAS of the local schools developing drug abuse prevention programs.
1. A program for center staff to acquaint them with the range of resocialization services available in the community for discharged inpatients.
7. Developing and staffing a prenatal care program for unwed adolescents.
2. A Saturday night social program for adult mentally retarded clients of the center.
8. A program with local primary school teachers to sensitize them to the problems of the single parent family.
3. A program of vocational and aptitude test-
9. Offering discussion groups for men and women coping with issues raised by the women’s liberation movement.
10. A program offering consultation to private nursing homes on ways to enrich the social experience of patients.
PROGRAMS IN TERTIARY PREVENTION
ing for all newly-released outpatients with appropriate referrals for training and job placement. 4. A program to escort patients discharged
from the in-patient unit to their first appointment for after-care. 5. A training program for paraprofessional staff of mental hospitals to enable them to
PERLMUTTER, VAYDA AND WOODBURN
537
vention for each of the thirty items according to Caplan’s definitions.s The reputational method of selection of experts was used, as panel membt:rs were identified by NIMH staff at the regional and national levels on the basis of their professional interests, activity, and publications on prevention. The panel consisted of a former president of the American Orthopsychiatric Association, seven academicians (including deans, chairmen of departments of psychiatry, professors in community psychiatry, education and psychiatry), two planners in community mental health servkes, and one NIMH staff member.* Validity was established if agreement Construct Validity among the judges was statistically sigThe major technical problem in the nificant at the .05 level (Binomial design of this instrument was one of Test) * O on each item of the instrument. construct validity: do the program items Thus the validation was item ‘by item, comprising the instrument in fact repre- allowing for the rejection of any nonsent their assigned prevention level? T o validated program using the above statest for validity, the following three- tistical criterion. stage procedure was used. Stage I consisted of the three mem- FINDINGS AND DISCUSSION Twenty-eight (93%) of the 30 items bers of the research team independently classifying forty program items in terms had agreement significant at the .05 of the level of prevention. The items level. TABLE1 presents the results by were retained only when there was con- prevention level, specifying the number sensus among the members; ten items of expert agreements and the significance were dropped because of lack of agree- level for each number of agreements. Six ment. or more agreements are statistically sigIn Stage ZI the list of agreements was nificant. submitted to an NIMH staff consultant When the three prevention levels are for his classification. The instrument was taken into account, we find little variadeveloped as a result of a combined con- tion between secondary and terl iary levsensus between the consultant (Stephen els-for these levels the extent of agreeE. Goldston, Ed.D., M.S.P.H.) and the ment among the experts is significant for research team. all the programs. The primary prevenIn Stage IZZ a panel of ten experts tion category, however, has the greatwas asked to specify the level of pre- est dispersion on number of agree-
reach patients self care, homemaking, and budgeting. 6. A program working with boarding home proprietors on the problems of after-care patients housed in these homes. 7. A short term homemaker service to assist mothers discharged from the in-patient service. 8. A program for halfway house residents to familiarize them with local transportation syst e m and local shopping facilities. 9. A “clerical service” for universities and businesses performed by hospitalized mental patients to provide them with income, and job experience. 10. A program for families of discharged patients about the needed supportive role of the transition period.
* An eleventh expert declined to participate because he felt the items were not sufficiently delineated (to be discussed in greater detail in the final section on critical dimensions).
DIFFERENTIATING PREVENTION PROGRAMS
Table I FREQUENCY DISTRIBUTION OF PROGRAMS BY NUMBER OF EXPERTS IN AGREEMENT AND BY PREVENTION LEVEL AGREEMENTS PROGRAMS 10 9 8
PRIMARY 2 2 3
6
I I
r
5 4
3 2
SECONDARY I .I
TERTIARY I
.wo .ooo
2 5 I
2 4 2
.003 .OI5 .05 I
-
.I34
-
I -
ments and is also the type of program that receives the greatest amount of agreement. Eight or more experts agree on the prevention level of 70% of the primary type programs (see TABLE 1). This is of interest particularly because primary prevention programs are the most controversial, and the crux of discussions about prevention often addresses the ambiguity of the programs to be developed. A major assignment of this exploratory research is to attempt to specify the issues or difficulties underlying the relationship between the conceptual and operational definitions of prevention programs. A reexamination of the primary prevention programs that were not validated show two thorny factors which have a potential confounding impact on the identification of a program as primary prevention. One factor is the borderline symptomology of the problem at hand; the other factor is the degree to which the target of the intervention can be associated with a therapeutic function. The two items that were not validated
-
-
-
I
-
P
-
.235
are in the primary prevention category : “a crisis oriented intervention program for rape victims based in emergency rooms of local hospitals;” and “a program offering consultation to private nursing homes on ways to enrich the social experience of patients.” Borderline symptomology appears to be a major point of difficulty in the categorization of primary prevention programs. By definition primary prevention is geared toward intervention prior to, or independent of, the development of symptoms of emotional disorder in a high risk population. In the case of the program for rape victims, the alternate prevention level for all disagreements was secondary prevention, indicating the respondents assumed the existence of emotional symptoms. Given a program that is offered to all rape victims regardless of any specific individual request for psychotherapeutic intervention or of the onset of emotional symptoms, a decision must be made whether a rape victim is “high risk” (and hence an appropriate response is a primary prevention activity)
PERLMUTTER, VAYDA AND W O O D B U R N
or whether emotional symptoms are inevitable and necessarily require therapeutic help.* In regard to the nursing home item, the modal designation was tertiary prevention ( N = 5 ) . The confusion of this item was undoubtedly due to the beneficiary group being designated as nursing home patients, rather than residents. The terminology creates ambiguity because primary prevention programs are generally not directed at persons or groups defined as “patients.” This demonstrates the urgency of accurate word usage, since it was the research team’s intention in this item to view nursing home residents as a “group at risk” (not as patients with psychiatric problems) ; consequently, the program was intended to promote mental health. These two items demonstrate the subtle and complex dimension in differentitating between primary and secondary strategies. Similar decisions must be made with respect to various life crises, such as divorce, illness, and death, among others. A second major point of difficulty identified by closer examination of the program descriptions is that the nature of the target population can play a preeminent role in the classification process. In those primary level programs that have the highest agreement, the target group was identified in terms of a clear-cut occupational or organizational affiliation not associated with a therapeutic function ( e . g . , PTA, teachers, ten-
539
ants). As the extent of agreement decreased, however, the primary level programs revolved around a target population identified via symptom-linked characteristics: (e.g., unwed adolescents, marriage counselors, parents of crippled children). Looking at the secondary level programs with the highest amount of disagreement, we find a similar situation in that all disagreements are classified as primary. For these secondary programs, the target population is identified in occupational terms which can generally be viewed as independent of emotional disorder (e.g., general practitioners, managers in industry, police) .z CRITICAL DIMENSIONS
In order to address the complexities in characterizing the dimensions of the program items, the three specijied by the study team will be recalled: target group, technique, and goals of the program. In addition to elaborating on target group and goals, several other dimensions must be discussed, including beneficiary of the program and organizational domain. In regard to target groups, it was emphasized that the target of the. intervention must be clearly specified for this is a central indicator of the level of the prevention activity. Furthermore, the target group must be differentiated from the beneficiary of the program, a dimension that must be added. For example, the fifth program item in the tertiary prevention grouping is a “training program for paraprofessional staff of mental hos-
* The following criteria, defined in our NIMH proposal, were suggestive of our thinking about what constitutes primary prevention and served as the basis for designing the research instruments. Primary prevention activities constitute those activities that are: 1 ) directed at persons or groups nor defined as patients; 2) directed usually at groups-at-risk; 3 ) concerned with contextual rather than individual functioning (e.g., schools, boarding homes, etc., ils systems); and 4) designed to maintain healthy functioning rather than meliorate pathology (e.g., well baby clinics, vocational counseling, etc.) .
540
DIFFERENTIATING PREVENTION PROGRAMS
pitals to enable them to teach patients self care, homemaking and budgeting.” The target of the intervention in this instance is the paraprofessional staff, but the beneficiaries of the program are the patients. The target group for participation in the program is not necessarily the beneficiary for preventive impact. What is critical here to the classification process is the prevention level achieved for the beneficiary, not the target group, of the program. Furthermore, the target group, if different from the beneficiary, may also be gaining primary or secondary level impact as an indirect effect of the ~ r o g r a m . ~ The “goal” dimension is elaborated upon by the consultants as they identify the reality of overlapping goals and multiple functions (both manifest and latent) of prevention programs. Several of the respondents addressed the difficulty in making the classification decision since they were asked to classify the program in only one prevention category. Realistically, however, prevention programs will have more than one kind of preventive impact:
.
. . in practice primary, secondary and tertiary elements overlap, and a decision on which element predominates depends in considerable degree on the ideas of the program directors and their staff regarding their mission as well as what turns out to be feasible in any particular situation.? Consequently the importance of the unique social-professional-political context of each program must be examined and understood as a crucial factor in defining the goals appropriate to the different levels of prevention activity. And, finally, the specification of the organization’s domain provides an essential dimension, as noted in the above discussion of the findings. This supports
the argument that institutions concerned with promoting mental health (e.g., recreation programs, schools, churches) would fall mainly into the primary rubric; institutions serving people with occasional emotional support (e.g., hospitals, social agencies, juvenile courts) would fall mainly into the secondary r ~ b r i c The . ~ manifest and latent functions of the institutions must be considered and made explicit in classifying and planning for prevention programs. CONCLUSIONS
Although the development of the instrument described in this paper is in its early stages, it is the hope of the research team that this discussion has clarified some of the definitional issues surrounding prevention programs, as well as identified new issues. While we recognize that in reality the different prevention levels operate on a continuum, the paper has addressed the issues separately only for the purpose of conceptual clarification. Hopefully this paper will stimulate other professionals to take the initiative in formulating and implementing new programs as well as in further refining this instrument and developing other tools that can aid in the clarification of the theoretical issues concerning the prevention of mental illness and the promotion of mental health. REFERENCES E. 1963, Primary prevention of mental and emotional disorders: a conceptual framework and action possibilities. Amer. I. Orthopsychiat. 33:832-847. 2. BOWER, E. 1972. KISS and kids: a mandate for prevention. Amer. J. Orthopsychiat. 42:556-565. 3. BOWER, E. 1974. Personal communication. 4. BROSKOWSKI, A. 1974. Personal communication.
I.
BOWER,
PERLMUTTER, VAYDA AND WOODBURN 5 . BROSKOWSKI, A. AND BAKER, F. 1974. Professional, organization and social barriers to primary prevention. Amer. J. Orthopsychiat. 44:707-7 19. 6. CAPLAN, 0. 1964. Principles of Preventive Psychiatry. Basic Books, New York. 7. CAPLAN, G. 1974. Personal communica-
tion. B.CAPLAN, 0. 1974. Support Systems and Community Mental Health: Lectures on Concept Development. Behavioral Publications, New York. (pp. 189-190) 9. COWEN, E., GARDNER, E. AND ZAX, M. 1967. Emergent Approaches to Mental Health Problems. Appleton-Century-Crofts, New York. 10. GLASSCOTE, R. AND GUDEMAN, J . 1969. The Staff of the Mental Health Center: A Field Study. Joint Information Service of APA and NAMH, Washington, D.C. 1 1 . COLDSTON, s. The Route to Primary Prevention Reconsidered: A Rebuttal. N.I.M.H., Division of Special Mental Health Programs, Washington, D.C. (mimeograph) 12. KESSLER, M. AND ALBEE, G. 1975. Primary prevention. Ann. Rev. Psychol. 26: 557591. 13. MECHANIC, D. 1969. Mental Health and So-
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cial Policy. Prentice-Hall, Englewood Cliffs, N.J. 14. National Institute of Mental Health. 1966. Consultation and Education: A Service of the Community Mental Health Center. NIMH, Washington, D.C. 15. PERLMUTTER, F. AND SILVERMAN, H. 1973. Conflict in C and E. Comm. Ment. Hlth J. 9: 116-122. 16. PERLMUTTER, F . AND SILVERMAlr, H. 1972. The Community Mental Health Center: a structural anachronism. SOC. Wk 17:7884. 17. REIFF, R. 1967. Mental health manpower and institutional change. I n Emcrgent Approaches to Mental Health Problems, E. Cowen et al, eds. Appleton-Century-Crofts, New York. 18. ROWLAND, L. 1969. Let’s try prevention. I n Distress in the City, W. Ryan, ed. Case Western Reserve University, Cleveland. I ~ . R Y A N ,w . , ed. 1969. Distress in the City. Case Western Reserve University, Cleveland. 2 0 . SIEGAL, s. 1956. Nonparametric Statistics, McGraw Hill, New York. (pp. 36-42) 21.VANANTWERP, M. 1971. The route to primary prevention. Comm. Ment. Hlth J. 7:183-188.
For reprints: Dr. Felice Perlmutter, Principal Investigator, Professor, School of Social Administration, Temple University, Ritter Addition (5th Floor), 13th and Columbia Avenue, Philadelphia, Pa. 19122
