MPLEMENTING THE PUBLIC HEALTH SOCIAL WORK FORWARD PLAN: A RESEARCH BASED PREVENTION CURRICULUM FOR SCHOOLS OF SOCIAL WORK KRISTINE SIEFERT, SRINIKA JAYARATNE, and LOUISE DOSS MARTIN In 1985, the Division of Maternal and Child Health of the U.S. Public Health Service funded a major working conference entitled "Public Health Social Work in Maternal and Child Health: A Forward Plan." Curriculum recommendations for schools of social work were made, including a recommendation for the integration of health and mental health content in the education of social workers within a public health conceptual framework. In 1986, the National lnstitute of Mental Health funded a three-year program to develop and evaluate a research-based prevention training curriculum for dissemination to schools of social work and other primary care professional schools. This article examines the Michigan Prevention Training and Curriculum Development Project from the perspective of the recommendations of the Public Health Social Work Forward Plan.
In 1985, the Division of Maternal and Child Health of the U.S. Public Health Service funded a major invitational working conference to develop a "Forward Plan" for public health social work. 'The conference, which was sponsored by the Columbia University School of Social Work, identified critical issues and made a number of
specific recommendations in the following areas: priorities for social work practice in maternal and child health; standards for public health social work practice at the federal, state, and local levels; knowledge and skins requirements for social workers; and recommendations for graduate and continuing education for public
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health social work practice. A summary of these recommendations was published in a report entitled Public Health Social Work in Maternal and Child Health: A Forward Plan (Gitterman, Black, & Stein, 1985). In 1986, the National Institute of Mental Health awarded the University of Michigan School of Social Work funding for a three-year research and development project to develop, implement, and disseminate a research-based preventive intervention training curriculum for social workers. This article reviews the Public Health Social Work Forward Plan recommendadons for school of social work curricula and examines the Michigan Prevention Training and Curriculum Development Project from the perspective of those recommendations. CURRICULA RECOMMENDATIONS FOR SCHOOLS OF SOCIAL WORK
The Public Health Social Work Forward Plan documents the need for graduate schools of social work to incorporate increased public health content into their curricula to prepare practitioners to work in a broad range of practice settings beyond those traditionally associated with public health. Black (1985) noted that public health concepts such as epidemiologic rates, populations at risk, relative and attributable risk, multicausality of disorders, and preventive interventions are directly relevant to social work practice in a variety of settings. However, in her review of surveys of health content in curricula of schools of social work, Black found widespread lack of coverage of content on epidemiologic principles and on preventive intervention. In addition, she presented data indicating that most students in health concentrations receive traditional clinical training with little attention to program development, administration, and evaluation. Finally, Black cited Caroff and Mailick's (1985) finding that few social work students were placed in community-based and primary care settings compared with tertiary care hospitals and that few field placements provided opportunities for macrolevel intervention and consultation experiences. 18
The Forward Plan identified several barders to increasing public health content in graduate social work curricula. Lack of space within the master of social work (MSW) curriculum is, as Black (1985) noted, a "constant source of tension" (p. 163). In addition; too few faculty and field instructors are educated in public health concepts, and field instructors who are knowledgeable about public health social work practice have too little input into social work curricula. Based on the needs and barriers identified at the conference, the Forward Plan made a number of recommendations, including the development and dissemination of curricular materials designed to infuse public health social work content into graduate social work education, the development of strategies for faculty development, and increased involvement of field personnel with public health expertise in classroom teaching, as well as reciprocal involvement by faculty in relevant agency programs. In addition, the Forward Plan recommended that concentrations in schools of social work integrate health and mental health content within a public health framework and that curricula include content on race, ethnicity, cultural diversity, human sexuality, and the impact of each on health status. MICHIGAN PREVENTION TRAINING AND CURRICULUM DEVELOPMENT PROJECT
The Michigan Prevention Training and Curriculum Development Project is a three-year, National Institute of Mental Health—supported research and development project designed to train social work students to use research findings about primary and early secondary prevention in their professional practice. It uses an epidemiologically oriented framework to identity high-risk populations and to develop preventive intervention programs on their behalf. This framework assumes that by identifying significant stressors, as well as those variables mediating their impact, students can design and implement specific interventions to eliminate or modify risk factors and to enhance those conditions that confer protection against physical and mental disorders.
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The project embodies the following principles: a perspective in which health and mental health are conceptualized holistically as positive wellbeing, and not merely the absence of disease; a developmental perspective emphasizing competence and mastery as well as vulnerability over the life cycle; knowledge of the impact of individual and environmental risk factors in the etiology and prevention of health and mental health disorders; an understanding of the protective function of social support; familiarity with concepts and strategies from epidemiology; comprehension of research design and methodology appropriate to prevention; and appreciation of the need to intervene at multiple levels using a range of preventive strategies (Albee, 1980; Bloom, 1982; Price, 1982; Siefert, 1983, 1986). To promote dissemination, the Michigan model is based on the professional foundation content areas required by the Council on Social Work Education for accreditation of schools of social work: human behavior and the social environment, social work practice, research, field practicum, and social welfare policies and services. Students are required to take three courses that have been specifically developed for the grant: "Preventive Intervention in Social Work," "Prevention Research Seminar," and "Prevention Practicum Seminar." In addition, students are advised to choose one of three courses in human behavior and the social environment: a course on human development over the life cycle, a course on the social epidemiology of health and illness, or a course on mental disorders with an emphasis on a developmental approach. Students also take one of two courses on social welfare policies and services: "The U.S. Health Care Systems" or "Human Resources and the Workplace." To illustrate how the project has incorporated the recommendations of the Forward Plan, the content of the three required courses and one of the recommended courses, "Social Epidemiology of Health and Illness," is briefly presented. Curriculum Content
Preventive Intervention in Social Work. "Preventive Intervention in Social Work" is a full-
semester course that presents prevention and health promotion as integral components of social work practice. The course emphasizes the need to intervene at the micro- and macrolevels simultaneously. Special attention is focused on identifying and providing outreach to populations at risk and on designing and implementing preventive services that are responsive to the needs of underserved groups, such as racial and ethnic minorities, women, and physically disabled people. The course also reviews the history of prevention in social work, the current knowledge base for prevention in health and mental health, and ethical issues in the design and implementation of preventive interventions. Students are taught to use epidemiologic methods to identify individuals, families, and groups at risk for health and mental health disorders; to practice assessment procedures with an emphasis on quality-of-life concerns and social problem analysis; to implement clinical and systems-level preventive interventions from an ecological perspective; and to evaluate the effectiveness of their interventions. A major component of the course is teaching students to use the PRECEDE model for planning and implementing preventive interventions (Green, Kreuter, Deeds, & Partridge, 1980). PRECEDE, an acronym for predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation, is a widely used framework for the development of health programs. It is also a useful tool for policy and program analysis. This model is especially well-suited to social work practice because it addresses social and environmental as well as individual and behavioral aspects of health problems. PRECEDE consists of seven phases, beginning with assessment of the quality of life of a given population. Subsequent phases include identifying the health problems contributing to the social problems identified by the needs assessment, setting priorities, identifying behavioral and nonbehavioral factors associated with the problem selected for intervention, determining which factors influencing change should be targeted, and selecting and implementing appropriate clinical and macrolevel strategies for intervention. Students review a number of
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potential interventions ranging from individual and group counseling and education to advocacy, social action, and community development. Students then conduct an administrative diagnosis to assess needed and available resources, to plan their allocation, and to identify organizational and extraorganizational barriers to implementing the intervention. Evaluation is a continuous and integral part of the PRECEDE framework, and students are familiarized with process, impact, and outcome levels of evaluation and with appropriate evaluative designs. The course is designed to complement the re-
search and practicum seminars. Table 1 presents sample content and representative source materials for selected sessions of the course. Prevention Research Seminar. The "Prevention Research Seminar" is a research course with a preventive focus. The course presents basic research principles, including measurement, design, and analysis. Students are expected to show beginning competence in the operationalization of these principles; they demonstrate their competence by critically analyzing published reports and by incorporating a sound research design into the development of a
Table 1. Mustrative Content and Source Materials for "Preventive Intervention in Social Work" Course Session
Topics Covered
Readings
Session 1: Prevention in social work
Case example of high-risk situation and discussion of indications for preventive intervention at individual, family, and community levels History of prevention in social work; criticisms and controversies Prevention and the ecological perspective in social work practice
Germain, C., & Gitterman, A. (1987). Ecologica) perspective. In A. Minahan (Ed.in-Chief) , Encyclopedia of social work (18th ed., pp. 488-489). Silver Spring, MD: National Association of Social Workers. Gilbert, N. (1982). Policy issues in primary prevention. Social Work, 27, 293-297. Roskin, M. (1980). Integration of primary prevention into social work practice. Social Work, 25, 192-196. Siefert, K. (1983). An examplar of primary prevention in social work: The SheppardTowner Act of 1921. Social Work in Health Care, 9(1), 87-103. Wittman, M. (1977). Application of knowledge about prevention in social work education and practice. Social Work in Health Care, 3(1), 37-47.
Sessions 8-11: Strategies for preventive inter- vention
Overview of prevention strategies; individual, family, and small-group focused approaches. Systems level interventions. Need to intervene at multiple levels simultaneously Specific strategies: skill development, individual instruction, counseling, modeling, peer-group discussion, lecture, mass media, programmed learning, simulation and games, modeling, life-education groups, self-help, consultation, crisis intervention, advocacy, community development, social action, organizational change, and legislation Selection of strategies according to characteristics of health/mental health problem; behavioral or nonbehavioral target; and predisposing, reinforcing, and enabling factors Illustration of integrating micro- and macrolevel approaches
Apgar, K., & Coplan, J. (1985). New perspectives on structured life education groups. Social Work, 30, 128-143. Beaver, M., & Miller, D. (1985). Interpersona] practice with the well elderly. In Clinical social work practice with the elderly (pp. 102-133). Homewood, IL: Dorsey Press. Black, R., Dornan, D. H., 8c Allegrante, J. P. (1986). Challenges in developing health promotion services for the chronically Social Work, 31, 287-293. Comer, J., & Hamilton-Lee, M. (1982). Support systems in the black community. In D. Biegel & A. Naparstek (Eds.), Community support systems and mental health (pp. 121-136). New York: Springer. Green, W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education planning. Palo Alto, CA: Mayfield.
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Table 1. Continued Session
Topics Covered
Readings Herrerias, C. (1988). Prevention of child abuse in Hispanics. Journal of Primary Prevention, 9(12), 104-119. Katz, A., & Hermalin, J. (1987). Self-help and prevention. In J. Hermalin &J. Morell (Eds.), Prevention planningin mental health (pp. 157-190). Newbury Park, CA: Sage. Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press. Roberts-DeGennaro, M. (1986). Building coalitions for political advocacy. Social Work, 31, 308-313. Shachnow, J. (1987). Preventive interven. tion with children of hospitalized psychia tric patients. American Journal of Orthopsychiatry, 57(1), 66-77. Siefert, K., & Martin, L. (1988). Preventing black maternal mortality: A challenge for the 90's. Journal of Primary Prevention, 9(2), 57-65. Stanton, G. (1986). Preventive intervention with stepfamilies. Social Werk, 31, 201-206. Tableman, D., Feis, C., Marciniak, D., & Howard, D. (1985). Stress management training for low income women. Prevention in Human Services, 3(4), 71-85. Weiss, J. 0., Karkalits, J. E., Bishop, K. K, Paul, N. W., 8c Dickman, F. (Eds.). (1986). Genetics support groups (pp. 128-138). White Plains, NY: March of Dimes.
Administrative diagnosis: within-program Sessions 12 and 13: Implementing analysis, within-organization analysis, prevention programs interorganizational analysis Assessment of available resources, allocation of resources, budgeting, program-timing, using PERT (program evaluation and review technique) Processes of influencing employing organizations: demonstration, collaboration, persuasion, conflict Reducing resistance to primary prevention: changing knowledge, values, professional traditions Examples of implementing preventive interventions across the life cycle and among special populations
preventive intervention project, which is actually implemented the following term. Research issues unique to prevention are covered through the critical reading of prevention research studies and in class discussions. Prevention Practicum Seminar. The "Prevention Practicum Seminar" includes two consecu-
Germain, C., & Gitterfnan, A. (1980). Professional influence: From case to cause. In The life model of social work practice (pp. 297-341). New York: Columbia University Press. Green, W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education planning. Palo Alto, CA: Mayfield. Nance, K. (1982) . Understanding and overcoming resistance to primary prevention. Social Work Research E..9' Abstracts, 18(3), 32-40.
tive courses designed to help students integrate the content from the preventive intervention and prevention research courses and apply their knowledge in the design and implementation of a prevention project of their choice. For reasons discussed later, not all students have been able to conduct prevention projects in their field
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placements. In addition, even in those placements in which students are able to develop and implement a prevention project, field instructors are not necessarily familiar enough with the concepts and strategies of prevention to provide guidance (Gitterman et al., 1985). Thus, although the activities conducted by the students in these seminars count toward the requirements for MSW practicum hours, the student projects require supervision by the project staff. Students use the class as a sounding board for their ideas on the design and development of their projects; conduct relevant literature reviews; practice specific intervention techniques; evaluate their interventions; and produce manuals describing the design, content, and implementation of their projects with the aim of facilitating replication. Because the actual prevention practicum is time-limited--one day per week for one term— student projects are generally conceived of in terms of a one-time intervention, usually in a workshop format. Thus, there is litde opportunity for students to assess long-term impact or outcome, and the emphasis of the practicum experience is on designing and implementing the intervention and evaluating its immediate impact. This is a practical necessity, rather than one dictated by theoretical or research integrity, and the need for ongoing preventive efforts and long-term follow-up is carefully discussed (Lorion, 1983; Price, Cowen, Lorion, & RamosMcKay, 1989). Most students work in groups of three to six; given the volume of work and nature of the practicum, individual projects are not only discouraged but would be almost impossible to carry out. Student projects have been diverse, ranging from an ongoing parenting education and resource group for goor single mothers living in the inner city to burnout prevention workshops for employees in health and mental health settings (Jayaratne & Siefert, 1989). One project resulted in the students being asked to repeat the program for other employees. Another student project taught problem-solving skins to a group of teenage parents; another project, "Steps to Better Step-parenting," provided anticipatory guidance and education to promote optimal adjustment for blended families. 22
An especially challenging and rewarding experience for students was developing and implementing a workshop designed to promote better communication skills among adolescents. This workshop included content on the prevention of acquired immune deficiency syndrome; students gained experience in outreach and collaboration with community agencies in ereparing for the workshop, as well as learning how to conduct specific preventive interventions such as teaching problem-solving and communication skiffs. Although the student projects themselves have been diverse, their content has revolved around two essential components: (1) the prevention of negative health and mental health outcomes produced by environmental stressors and (2) strategies both to help the individual identify and cope with the stressors and to change the environment. Social Epidemiology of Health and IIIness. "Social Epidemiology of Health and Illness" is a course designed to provide students with a knowledge base and methodology for the scientific study of the social and behavioral determinants of health and illness and of specific physical and mental disorders in their social and behavioral contexts. Concepts and strategies from epidemiology are presented, such as measures of incidence and prevalence, relative and attributable risk, multicausa) models, the natural history of a disorder, and levels of prevention. Special attention is given to the role of such variables as age, sex, social class, race, ethnicity, education, occupation, mantal status, sexual orientation, religion, and residence in the etiology, prevention, treatment, and outcome of health and mental health disorders. The nature and effects of stressful life events and conditions, social support, and adaptive versus maladaptive coping are addressed, as is the role of attributions in health and illness behavior. This course is cross-listed with the School of Public Health and exposes social work students to students from other disciplines as well as to public health concepts. Evaluation and Dissemination
As part of the program, a comprehensive evaluation effort has been undertaken. Although this
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evaluation is still in progress, preliminary findings are encouraging. All incoming students at the University of Michigan School of Social Work for a period of two years were requested to complete a pretest questionnaire mailed to them. The questionnaire was designed to assess student knowledge of theory, research, practice, and management issues related to the development and implementation of prevention programs. In all, 266 out of 314 questionnaires were returned, a response rate of 84.7 percent. A posttest questionnaire was mailed approximately one month before graduation to the 266 students who completed the pretest. The response rate for the posttest was 77.4 percent (n = 206). In addition, pretest and posttest information was gathered from the 28 prevention program participants. The evaluation plan called for the comparison of the prevention program students with nonprogram students. Students will also be compared on the basis of full participation, pardal enrollment, or nonenrollment in prevention program courses. In addition, samples of social work students at four other universities have been administered the questionnaires and will serve as a control group for the students at the University of Michigan. The bar graphs in Figure 1 compare the responses of prevention program students with nonprogram students at the University of Michigan on four representative questions related to the acquisition of knowledge of prevention theory, research, practice, and management. The proportion of prevention program students who reported "somewhat" or "high" levels of confidence in their knowledge of theory, research, and practice was considerably greater than the nonprogram students for these and other evaluation questions. Although larger proportions of both groups expressed relatively low levels of confidence in dealing with issues related to management, these preliminary data strongly suggest that the prevention program has been successful in providing a curriculum and training experience that has resulted in a unique knowledge base compared to nonprogram participants at the University of Michigan. Outlines of the courses developed for the prevention program and program evaluation
material will be mailed to all graduate schools of social work following completion of the project. For the three required courses developed specifically for the prevention program, extensive information will be provided to facilitate their incorporation into school curricula. For the supporting courses, relevant literature and suggestions for incorporation of prevention content into existing core courses will be provided. DISCUSSION AND IMPLICATIONS FOR THE FUTURE
Some of the barriers to increasing public health content in social work curricula described here have been encountered in implementation of the Michigan Training and Curriculum Development Project. Due to unanticipated faculty turnover, the Jack of available faculty with expertise in prevention resulted in some modifications of the original plan. Lack of an orientafion to prevention on the part of field instruction agencies, also noted as a banier in the Forward Plan, led to a number of students developing and implementing their prevention projects outside of their field placements. As noted earlier, however, student evaluations of individual courses and preliminary findings from the formal evaluation indicate that the program has been effective in accomplishing its goals, and the student projects have been exemplary. Moreover, the experience of independently gaining access to target populations, securing the cooperation of relevant community organizations and gatekeepers, obtaining the necessary resources, and actually carrying out the projects without an agency base has provided students with hands-on experience in the process of introducing innovation and change. In addition, anecdotal evidence suggests that although most graduates of the project are employed in "traditional" agencies, they are using their prevention training to develop and implement innovative programs. For example, a graduate who is employed in a treatment program for survivors of incest reported that she is developing a child sexual abuse prevention program within her agency.
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expressing confidence: practice
% students
expressing confidence: theory
% students
Linle
Level 01Conlldence
Somewhat
High
Trainee
0
10
20
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40
little
Somewhat
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level of Confidence
o
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50 % students expressing confidence: research
60
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Lit1fe
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In Control
• Trainee
Lit1fe
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High
W Control
• Trainee
Q: Advi.. an agancy on th. type 01r....rch design to us. lor .valuatlng a new prevention program?
o
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% students 40 expressing confidence: management 30
50
60
70
Q: Develop a budget to cover the coets 01evaluetlng a prevention program?
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oriented technlqu.s to Its tr.atm.nt servlc.s?
• Trainee
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Q: Advls. a county m.ntal health sg.ncy on how to sdd more prev.ntlon-
o
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40
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Q: Describe the rol.. 01socUlI support snd other environmental Isctors in promoting mentel health?
Figure 1. Student Responses to Evaluation Questions
Nevertheless, the scarcity of faculty with expertise in preventive intervention and the paucity of agencies providing preventive services support the need for public health social work training in social work education at the continuing education, doctoral, and postdoctoral levels as well as in MSW programs. Training at the doctoral level is especially important; as Black (1985) pointed out, doctoral programs are the major source of social work faculty. The problem of "space" within the curriculum has been an ongoing concern. However, the deliberate integration of the project with the standard MSW curriculum has maximized the availability of electives and should facilitate replication of the model by other schools of social work. In addition, the inclusion of content addressing a broad range of populations (Table 1) should promote dissemination. If dissemination of this model is successful, concepts from the Forward Plan will be integrated into mainstream social work education. Presentation of the project at Council on Social Work Education annual meetings and at the annual meeting of the American Public Health Association have generated interest among social work faculty (Bloom, Brown, Collins, Jayaratne, & Siefert, 1988; Jayaratne & Siefert, 1987; Siefert, Martin, & Jayaratne, 1988), but a number of additional issues related to the barders identified in the Forward Plan have been raised. The traditional view of health and mental health as separate domains is still held by many social workers; some faculty who do not understand the difference between public health and clinical medicine fear that combining the two fields may lead to a "medicalization" of social work practice. Others have expressed a valid concern that there are important differences in the policy, funding, and organization of service delivery in health and mental health care that should not be ignored (Carlton, 1987). Although the societal determinants of differences in the health and mental health care systems must be acknowledged, probably the most compelling argument for combining the two fields is the research-based observation that physical disorders have psychological components and that some major mental disorders are at
least in part biologically determined (Broskowski, 1981; Carlton, 1987). Moreover, utilization studies indicate that the majority of individuals suffering from a mental disorder receive services in the primary health care sector, rather than in the specialty mental health sector (Broskowski, 1981). Using the National Association of Social Workers' (NASW) definition of public health social work services as involving "activities which include prevention, diagnosis, treatment, maintenance and rehabilitation . . . provided in a variety of settings such as: public health programs, general and specialty hospitals, community health centers, community mental health centers and hospices" (Leukefeld, 1985, p. 2), Leukefeld estimated that nearly half the membership of NASW is engaged in public health social work practice and that at least 8,000 students are in public health social work training. Nevertheless, the majority of these social workers do not identify themselves as public health social workers, and it appears that lack of understanding of the nature of public health social work practice is a barrier to incorporating public health concepts in social work education. These findings support the need for prevention training at multiple levels, including the continuing education of practitioners. The tension between proponents of microversus macrolevel practice is another barrier to incorporating a preventive perspective, which requires that social workers intervene at multiple levels simultaneously (Siefert, 1983, 1986). A detailed review of the micro-macro debate is beyond the scope of this article, but Watkins (1985) observed that the tendency of schools of social work to "track" students into micro- or macromethods results in students being proficient in only one method of intervention. Watkins stated that this is not adequate for public health'social work practice, which requires the ability to advocate and to intervene at the community level as well as to work directly with individuals and families. Similarly, Kumabe (1985) noted that the trend toward specialization tends to impede an integrative approach and "perpetuates dichotomous thinking, implying that a different set of knowledge and skins is involved" (p. 136). Again, this supports the need
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for public health social work training in doctoral programs, as well as at the master's and continuing education levels, because doctoral programs produce the faculty who in turn shape curricula. Implementing the Public Health Social Work Forward Plan is a formidable but exciting challenge that demands ongoing and innovative efforts. It is the authors' hope that the project described here will stimulate other such efforts to incorporate increased content from public health in social work education and practice. About the Authors
Kristine Siefert, PhD, MPH, is Associate Professor, and Srinika Jayaratne, PhD, is Professor, School of Social Work, University of Michigan, 1065 Frieze Building, Ann Arbor, MI 48109. Louise Doss Martin, MA, ACSW, is Captain, U.S. Public Health Service, National Health Service Corps, Rockville, MD. An earlier version of this paper was presented at the American Public Health Association Annual Meeting, Boston, November 15, 1988. This paper was coauthored by Louise Doss Martin in her private capacity. No official support or endorsement by the U.S. Department of Health and Human Services, Health Resources and Services Administration, or the Public Health Service is intended or should be inferred. The preparation of this paper was supported in part by NIMH Grant STC-9-5-T24-MH18773. References
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(pp. 159-165). Rockville, MD: Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services. Bloom, B. L. (1982). Advances and obstacles in prevention of mental disorders. In H. C. Schulberg & M. Killilea (Eds.), Principles and 26
practices of community mental health (pp. 126-
147). San Francisco: Jossey-Bass. Bloom, M., Brown, A., Collins, P., Jayaratne, S., & Siefert, K. (1988, March 7). The Michigan Prevention Training and Curriculum Development Project: Preventive intervention in social work. Pa-
per presented at the Council on Social Work Education Annual Program Meeting, Atlanta. Broskowski, A. (1981). The health-mental health connection. In A. Broskowski, E. Marks, & S. H. Budman (Eds.), Linking health and mental health (pp. 13-25). Beverly Hills, CA: Sage. Carlton, T. 0. (1987). Health/mental health: One field of practice or two? Health and Social Work, 12, 243-245. Caroff, P., & Mailick, M. (1985). Health concentrations in schools of social work: The state of the art. Health and Social Work, 10, 5-14. Gitterman, A., Black, R. B., & Stein, F. (Eds.). (1985). Public health social work in maternal and child health: A forward plan. Rockville, MD: Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services. Green, L. W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education planning. Palo Alto, CA: Mayfield. Jayaratne, S., & Siefert, K. (1987, March 8). Developing a research-based prevention curriculum. Paper presented at the Council on Social Work Education Annual Program Meeting, St. Louis. Jayaratne, S., & Siefert, K. (1989). Clinical training in prevention: Michigan model. Unpublished manuscript, University of Michigan, Ann Arbor. Kumabe, K. (1985). Knowledge and skill requirements for social work practice in maternal and child health. In A. Gitterman, R. B. Black, & F. Stein (Eds.), Public health social work in maternal and child health: A forward plan (pp. 133-147). Rockville, MD: Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services. Leukefeld, C. (1985, October). Public health social workers—who are we? American Public Health Association Social Work Section Newsletter,
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Lorion, R. (1983). Research issues in the design and evaluation of preventive interventions. In J. Bowker (Ed.), Education for primary prevention in social work (pp. 7-23). New York: Council on Social Work Education. Price, R. H. (1982). Priorities for prevention research: Linking risk factor and interuention research. Washington, DC: National Institute of Mental Health, Center for Studies of Prevention. Price, R. H., Cowen, E. L., Lorion, R. P., & RamosMcKay, J. (1989). The search for effective prevention programs: What we learned along the way. American Journ al of Orthopsychiatr y, 59, 49-58. Siefert, K. (1983). Using concepts from epidemiology to teach prevention. In J. Bowker (Ed.), Education for primary prevention in social work (pp. 54-74). NewYork: Council on Social Work Education. Siefert, K. (1986). Theoretical base for social work interventions. In E. Watkins (Ed.), Infant mormorbidity and childhood handicapping condi,
tions: Psychosocial factors (pp. 19-27). Rockville, MD: Bureau of Health Care Delivery and Assistance, Division of Maternal and Child Health, U.S. Department of Health and Human Services. Siefert, K., Martin, L. D., & Jayaratne, S. (1988, November 15). Implementing the Public Health Social Work Forward Plan: A research-based prevention curriculum for schools of social work. Paper presented to the American Public Health Association Annual Meeting, Boston. Watkins, E. (1985). The conceptual base for public health social work. In A. Gitterman, R. B. Black, & F. Stein (Eds.), Public health social work in maternal and child health: A forward plan (pp. 17-33). Rockville, MD: Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services. Accepted June 12, 1990
Social Support Systems in Practice A Generalist Approach by Lambert Maguire Social Support Systems in Practice shows social workers how to use social support systems with cognifive, psychodynamic, problem-solving, and task-centered interventions. It integrates evolving case management, networking, and self-help efforts and focuses on developing a better understanding of natural support systems.
ISBN 0-87101-189-1 (#1891) $19.95
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NASW PRESS AD-99 1011/91
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In 1985, the Division of Maternal and Child Health of the U.S. Public Health Service funded a major invitational working conference to develop a "Forward Plan" for public health social work. 'The conference, which was sponsored by the Columbia University School of Social Work, identified critical issues and made a number of
specific recommendations in the following areas: priorities for social work practice in maternal and child health; standards for public health social work practice at the federal, state, and local levels; knowledge and skins requirements for social workers; and recommendations for graduate and continuing education for public
CCC Code: 0360-7283/92 $3.00 © 1992, National Association of Social Workers, Inc.
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health social work practice. A summary of these recommendations was published in a report entitled Public Health Social Work in Maternal and Child Health: A Forward Plan (Gitterman, Black, & Stein, 1985). In 1986, the National Institute of Mental Health awarded the University of Michigan School of Social Work funding for a three-year research and development project to develop, implement, and disseminate a research-based preventive intervention training curriculum for social workers. This article reviews the Public Health Social Work Forward Plan recommendadons for school of social work curricula and examines the Michigan Prevention Training and Curriculum Development Project from the perspective of those recommendations. CURRICULA RECOMMENDATIONS FOR SCHOOLS OF SOCIAL WORK
The Public Health Social Work Forward Plan documents the need for graduate schools of social work to incorporate increased public health content into their curricula to prepare practitioners to work in a broad range of practice settings beyond those traditionally associated with public health. Black (1985) noted that public health concepts such as epidemiologic rates, populations at risk, relative and attributable risk, multicausality of disorders, and preventive interventions are directly relevant to social work practice in a variety of settings. However, in her review of surveys of health content in curricula of schools of social work, Black found widespread lack of coverage of content on epidemiologic principles and on preventive intervention. In addition, she presented data indicating that most students in health concentrations receive traditional clinical training with little attention to program development, administration, and evaluation. Finally, Black cited Caroff and Mailick's (1985) finding that few social work students were placed in community-based and primary care settings compared with tertiary care hospitals and that few field placements provided opportunities for macrolevel intervention and consultation experiences. 18
The Forward Plan identified several barders to increasing public health content in graduate social work curricula. Lack of space within the master of social work (MSW) curriculum is, as Black (1985) noted, a "constant source of tension" (p. 163). In addition; too few faculty and field instructors are educated in public health concepts, and field instructors who are knowledgeable about public health social work practice have too little input into social work curricula. Based on the needs and barriers identified at the conference, the Forward Plan made a number of recommendations, including the development and dissemination of curricular materials designed to infuse public health social work content into graduate social work education, the development of strategies for faculty development, and increased involvement of field personnel with public health expertise in classroom teaching, as well as reciprocal involvement by faculty in relevant agency programs. In addition, the Forward Plan recommended that concentrations in schools of social work integrate health and mental health content within a public health framework and that curricula include content on race, ethnicity, cultural diversity, human sexuality, and the impact of each on health status. MICHIGAN PREVENTION TRAINING AND CURRICULUM DEVELOPMENT PROJECT
The Michigan Prevention Training and Curriculum Development Project is a three-year, National Institute of Mental Health—supported research and development project designed to train social work students to use research findings about primary and early secondary prevention in their professional practice. It uses an epidemiologically oriented framework to identity high-risk populations and to develop preventive intervention programs on their behalf. This framework assumes that by identifying significant stressors, as well as those variables mediating their impact, students can design and implement specific interventions to eliminate or modify risk factors and to enhance those conditions that confer protection against physical and mental disorders.
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The project embodies the following principles: a perspective in which health and mental health are conceptualized holistically as positive wellbeing, and not merely the absence of disease; a developmental perspective emphasizing competence and mastery as well as vulnerability over the life cycle; knowledge of the impact of individual and environmental risk factors in the etiology and prevention of health and mental health disorders; an understanding of the protective function of social support; familiarity with concepts and strategies from epidemiology; comprehension of research design and methodology appropriate to prevention; and appreciation of the need to intervene at multiple levels using a range of preventive strategies (Albee, 1980; Bloom, 1982; Price, 1982; Siefert, 1983, 1986). To promote dissemination, the Michigan model is based on the professional foundation content areas required by the Council on Social Work Education for accreditation of schools of social work: human behavior and the social environment, social work practice, research, field practicum, and social welfare policies and services. Students are required to take three courses that have been specifically developed for the grant: "Preventive Intervention in Social Work," "Prevention Research Seminar," and "Prevention Practicum Seminar." In addition, students are advised to choose one of three courses in human behavior and the social environment: a course on human development over the life cycle, a course on the social epidemiology of health and illness, or a course on mental disorders with an emphasis on a developmental approach. Students also take one of two courses on social welfare policies and services: "The U.S. Health Care Systems" or "Human Resources and the Workplace." To illustrate how the project has incorporated the recommendations of the Forward Plan, the content of the three required courses and one of the recommended courses, "Social Epidemiology of Health and Illness," is briefly presented. Curriculum Content
Preventive Intervention in Social Work. "Preventive Intervention in Social Work" is a full-
semester course that presents prevention and health promotion as integral components of social work practice. The course emphasizes the need to intervene at the micro- and macrolevels simultaneously. Special attention is focused on identifying and providing outreach to populations at risk and on designing and implementing preventive services that are responsive to the needs of underserved groups, such as racial and ethnic minorities, women, and physically disabled people. The course also reviews the history of prevention in social work, the current knowledge base for prevention in health and mental health, and ethical issues in the design and implementation of preventive interventions. Students are taught to use epidemiologic methods to identify individuals, families, and groups at risk for health and mental health disorders; to practice assessment procedures with an emphasis on quality-of-life concerns and social problem analysis; to implement clinical and systems-level preventive interventions from an ecological perspective; and to evaluate the effectiveness of their interventions. A major component of the course is teaching students to use the PRECEDE model for planning and implementing preventive interventions (Green, Kreuter, Deeds, & Partridge, 1980). PRECEDE, an acronym for predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation, is a widely used framework for the development of health programs. It is also a useful tool for policy and program analysis. This model is especially well-suited to social work practice because it addresses social and environmental as well as individual and behavioral aspects of health problems. PRECEDE consists of seven phases, beginning with assessment of the quality of life of a given population. Subsequent phases include identifying the health problems contributing to the social problems identified by the needs assessment, setting priorities, identifying behavioral and nonbehavioral factors associated with the problem selected for intervention, determining which factors influencing change should be targeted, and selecting and implementing appropriate clinical and macrolevel strategies for intervention. Students review a number of
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potential interventions ranging from individual and group counseling and education to advocacy, social action, and community development. Students then conduct an administrative diagnosis to assess needed and available resources, to plan their allocation, and to identify organizational and extraorganizational barriers to implementing the intervention. Evaluation is a continuous and integral part of the PRECEDE framework, and students are familiarized with process, impact, and outcome levels of evaluation and with appropriate evaluative designs. The course is designed to complement the re-
search and practicum seminars. Table 1 presents sample content and representative source materials for selected sessions of the course. Prevention Research Seminar. The "Prevention Research Seminar" is a research course with a preventive focus. The course presents basic research principles, including measurement, design, and analysis. Students are expected to show beginning competence in the operationalization of these principles; they demonstrate their competence by critically analyzing published reports and by incorporating a sound research design into the development of a
Table 1. Mustrative Content and Source Materials for "Preventive Intervention in Social Work" Course Session
Topics Covered
Readings
Session 1: Prevention in social work
Case example of high-risk situation and discussion of indications for preventive intervention at individual, family, and community levels History of prevention in social work; criticisms and controversies Prevention and the ecological perspective in social work practice
Germain, C., & Gitterman, A. (1987). Ecologica) perspective. In A. Minahan (Ed.in-Chief) , Encyclopedia of social work (18th ed., pp. 488-489). Silver Spring, MD: National Association of Social Workers. Gilbert, N. (1982). Policy issues in primary prevention. Social Work, 27, 293-297. Roskin, M. (1980). Integration of primary prevention into social work practice. Social Work, 25, 192-196. Siefert, K. (1983). An examplar of primary prevention in social work: The SheppardTowner Act of 1921. Social Work in Health Care, 9(1), 87-103. Wittman, M. (1977). Application of knowledge about prevention in social work education and practice. Social Work in Health Care, 3(1), 37-47.
Sessions 8-11: Strategies for preventive inter- vention
Overview of prevention strategies; individual, family, and small-group focused approaches. Systems level interventions. Need to intervene at multiple levels simultaneously Specific strategies: skill development, individual instruction, counseling, modeling, peer-group discussion, lecture, mass media, programmed learning, simulation and games, modeling, life-education groups, self-help, consultation, crisis intervention, advocacy, community development, social action, organizational change, and legislation Selection of strategies according to characteristics of health/mental health problem; behavioral or nonbehavioral target; and predisposing, reinforcing, and enabling factors Illustration of integrating micro- and macrolevel approaches
Apgar, K., & Coplan, J. (1985). New perspectives on structured life education groups. Social Work, 30, 128-143. Beaver, M., & Miller, D. (1985). Interpersona] practice with the well elderly. In Clinical social work practice with the elderly (pp. 102-133). Homewood, IL: Dorsey Press. Black, R., Dornan, D. H., 8c Allegrante, J. P. (1986). Challenges in developing health promotion services for the chronically Social Work, 31, 287-293. Comer, J., & Hamilton-Lee, M. (1982). Support systems in the black community. In D. Biegel & A. Naparstek (Eds.), Community support systems and mental health (pp. 121-136). New York: Springer. Green, W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education planning. Palo Alto, CA: Mayfield.
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Table 1. Continued Session
Topics Covered
Readings Herrerias, C. (1988). Prevention of child abuse in Hispanics. Journal of Primary Prevention, 9(12), 104-119. Katz, A., & Hermalin, J. (1987). Self-help and prevention. In J. Hermalin &J. Morell (Eds.), Prevention planningin mental health (pp. 157-190). Newbury Park, CA: Sage. Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press. Roberts-DeGennaro, M. (1986). Building coalitions for political advocacy. Social Work, 31, 308-313. Shachnow, J. (1987). Preventive interven. tion with children of hospitalized psychia tric patients. American Journal of Orthopsychiatry, 57(1), 66-77. Siefert, K., & Martin, L. (1988). Preventing black maternal mortality: A challenge for the 90's. Journal of Primary Prevention, 9(2), 57-65. Stanton, G. (1986). Preventive intervention with stepfamilies. Social Werk, 31, 201-206. Tableman, D., Feis, C., Marciniak, D., & Howard, D. (1985). Stress management training for low income women. Prevention in Human Services, 3(4), 71-85. Weiss, J. 0., Karkalits, J. E., Bishop, K. K, Paul, N. W., 8c Dickman, F. (Eds.). (1986). Genetics support groups (pp. 128-138). White Plains, NY: March of Dimes.
Administrative diagnosis: within-program Sessions 12 and 13: Implementing analysis, within-organization analysis, prevention programs interorganizational analysis Assessment of available resources, allocation of resources, budgeting, program-timing, using PERT (program evaluation and review technique) Processes of influencing employing organizations: demonstration, collaboration, persuasion, conflict Reducing resistance to primary prevention: changing knowledge, values, professional traditions Examples of implementing preventive interventions across the life cycle and among special populations
preventive intervention project, which is actually implemented the following term. Research issues unique to prevention are covered through the critical reading of prevention research studies and in class discussions. Prevention Practicum Seminar. The "Prevention Practicum Seminar" includes two consecu-
Germain, C., & Gitterfnan, A. (1980). Professional influence: From case to cause. In The life model of social work practice (pp. 297-341). New York: Columbia University Press. Green, W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education planning. Palo Alto, CA: Mayfield. Nance, K. (1982) . Understanding and overcoming resistance to primary prevention. Social Work Research E..9' Abstracts, 18(3), 32-40.
tive courses designed to help students integrate the content from the preventive intervention and prevention research courses and apply their knowledge in the design and implementation of a prevention project of their choice. For reasons discussed later, not all students have been able to conduct prevention projects in their field
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placements. In addition, even in those placements in which students are able to develop and implement a prevention project, field instructors are not necessarily familiar enough with the concepts and strategies of prevention to provide guidance (Gitterman et al., 1985). Thus, although the activities conducted by the students in these seminars count toward the requirements for MSW practicum hours, the student projects require supervision by the project staff. Students use the class as a sounding board for their ideas on the design and development of their projects; conduct relevant literature reviews; practice specific intervention techniques; evaluate their interventions; and produce manuals describing the design, content, and implementation of their projects with the aim of facilitating replication. Because the actual prevention practicum is time-limited--one day per week for one term— student projects are generally conceived of in terms of a one-time intervention, usually in a workshop format. Thus, there is litde opportunity for students to assess long-term impact or outcome, and the emphasis of the practicum experience is on designing and implementing the intervention and evaluating its immediate impact. This is a practical necessity, rather than one dictated by theoretical or research integrity, and the need for ongoing preventive efforts and long-term follow-up is carefully discussed (Lorion, 1983; Price, Cowen, Lorion, & RamosMcKay, 1989). Most students work in groups of three to six; given the volume of work and nature of the practicum, individual projects are not only discouraged but would be almost impossible to carry out. Student projects have been diverse, ranging from an ongoing parenting education and resource group for goor single mothers living in the inner city to burnout prevention workshops for employees in health and mental health settings (Jayaratne & Siefert, 1989). One project resulted in the students being asked to repeat the program for other employees. Another student project taught problem-solving skins to a group of teenage parents; another project, "Steps to Better Step-parenting," provided anticipatory guidance and education to promote optimal adjustment for blended families. 22
An especially challenging and rewarding experience for students was developing and implementing a workshop designed to promote better communication skills among adolescents. This workshop included content on the prevention of acquired immune deficiency syndrome; students gained experience in outreach and collaboration with community agencies in ereparing for the workshop, as well as learning how to conduct specific preventive interventions such as teaching problem-solving and communication skiffs. Although the student projects themselves have been diverse, their content has revolved around two essential components: (1) the prevention of negative health and mental health outcomes produced by environmental stressors and (2) strategies both to help the individual identify and cope with the stressors and to change the environment. Social Epidemiology of Health and IIIness. "Social Epidemiology of Health and Illness" is a course designed to provide students with a knowledge base and methodology for the scientific study of the social and behavioral determinants of health and illness and of specific physical and mental disorders in their social and behavioral contexts. Concepts and strategies from epidemiology are presented, such as measures of incidence and prevalence, relative and attributable risk, multicausa) models, the natural history of a disorder, and levels of prevention. Special attention is given to the role of such variables as age, sex, social class, race, ethnicity, education, occupation, mantal status, sexual orientation, religion, and residence in the etiology, prevention, treatment, and outcome of health and mental health disorders. The nature and effects of stressful life events and conditions, social support, and adaptive versus maladaptive coping are addressed, as is the role of attributions in health and illness behavior. This course is cross-listed with the School of Public Health and exposes social work students to students from other disciplines as well as to public health concepts. Evaluation and Dissemination
As part of the program, a comprehensive evaluation effort has been undertaken. Although this
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evaluation is still in progress, preliminary findings are encouraging. All incoming students at the University of Michigan School of Social Work for a period of two years were requested to complete a pretest questionnaire mailed to them. The questionnaire was designed to assess student knowledge of theory, research, practice, and management issues related to the development and implementation of prevention programs. In all, 266 out of 314 questionnaires were returned, a response rate of 84.7 percent. A posttest questionnaire was mailed approximately one month before graduation to the 266 students who completed the pretest. The response rate for the posttest was 77.4 percent (n = 206). In addition, pretest and posttest information was gathered from the 28 prevention program participants. The evaluation plan called for the comparison of the prevention program students with nonprogram students. Students will also be compared on the basis of full participation, pardal enrollment, or nonenrollment in prevention program courses. In addition, samples of social work students at four other universities have been administered the questionnaires and will serve as a control group for the students at the University of Michigan. The bar graphs in Figure 1 compare the responses of prevention program students with nonprogram students at the University of Michigan on four representative questions related to the acquisition of knowledge of prevention theory, research, practice, and management. The proportion of prevention program students who reported "somewhat" or "high" levels of confidence in their knowledge of theory, research, and practice was considerably greater than the nonprogram students for these and other evaluation questions. Although larger proportions of both groups expressed relatively low levels of confidence in dealing with issues related to management, these preliminary data strongly suggest that the prevention program has been successful in providing a curriculum and training experience that has resulted in a unique knowledge base compared to nonprogram participants at the University of Michigan. Outlines of the courses developed for the prevention program and program evaluation
material will be mailed to all graduate schools of social work following completion of the project. For the three required courses developed specifically for the prevention program, extensive information will be provided to facilitate their incorporation into school curricula. For the supporting courses, relevant literature and suggestions for incorporation of prevention content into existing core courses will be provided. DISCUSSION AND IMPLICATIONS FOR THE FUTURE
Some of the barriers to increasing public health content in social work curricula described here have been encountered in implementation of the Michigan Training and Curriculum Development Project. Due to unanticipated faculty turnover, the Jack of available faculty with expertise in prevention resulted in some modifications of the original plan. Lack of an orientafion to prevention on the part of field instruction agencies, also noted as a banier in the Forward Plan, led to a number of students developing and implementing their prevention projects outside of their field placements. As noted earlier, however, student evaluations of individual courses and preliminary findings from the formal evaluation indicate that the program has been effective in accomplishing its goals, and the student projects have been exemplary. Moreover, the experience of independently gaining access to target populations, securing the cooperation of relevant community organizations and gatekeepers, obtaining the necessary resources, and actually carrying out the projects without an agency base has provided students with hands-on experience in the process of introducing innovation and change. In addition, anecdotal evidence suggests that although most graduates of the project are employed in "traditional" agencies, they are using their prevention training to develop and implement innovative programs. For example, a graduate who is employed in a treatment program for survivors of incest reported that she is developing a child sexual abuse prevention program within her agency.
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expressing confidence: practice
% students
expressing confidence: theory
% students
Linle
Level 01Conlldence
Somewhat
High
Trainee
0
10
20
30
40
little
Somewhat
High
level of Confidence
o
10
20
30
40
!fI Control
50 % students expressing confidence: research
60
70
60
50
Lit1fe
Somewhat Level 01Confidence
High
In Control
• Trainee
Lit1fe
Somewhat Level 01Confidence
High
W Control
• Trainee
Q: Advi.. an agancy on th. type 01r....rch design to us. lor .valuatlng a new prevention program?
o
10
20
% students 40 expressing confidence: management 30
50
60
70
Q: Develop a budget to cover the coets 01evaluetlng a prevention program?
70
80
90
oriented technlqu.s to Its tr.atm.nt servlc.s?
• Trainee
!fI Control
•
Q: Advls. a county m.ntal health sg.ncy on how to sdd more prev.ntlon-
o
10
20
30
40
50
60
70
80
90
100
Q: Describe the rol.. 01socUlI support snd other environmental Isctors in promoting mentel health?
Figure 1. Student Responses to Evaluation Questions
Nevertheless, the scarcity of faculty with expertise in preventive intervention and the paucity of agencies providing preventive services support the need for public health social work training in social work education at the continuing education, doctoral, and postdoctoral levels as well as in MSW programs. Training at the doctoral level is especially important; as Black (1985) pointed out, doctoral programs are the major source of social work faculty. The problem of "space" within the curriculum has been an ongoing concern. However, the deliberate integration of the project with the standard MSW curriculum has maximized the availability of electives and should facilitate replication of the model by other schools of social work. In addition, the inclusion of content addressing a broad range of populations (Table 1) should promote dissemination. If dissemination of this model is successful, concepts from the Forward Plan will be integrated into mainstream social work education. Presentation of the project at Council on Social Work Education annual meetings and at the annual meeting of the American Public Health Association have generated interest among social work faculty (Bloom, Brown, Collins, Jayaratne, & Siefert, 1988; Jayaratne & Siefert, 1987; Siefert, Martin, & Jayaratne, 1988), but a number of additional issues related to the barders identified in the Forward Plan have been raised. The traditional view of health and mental health as separate domains is still held by many social workers; some faculty who do not understand the difference between public health and clinical medicine fear that combining the two fields may lead to a "medicalization" of social work practice. Others have expressed a valid concern that there are important differences in the policy, funding, and organization of service delivery in health and mental health care that should not be ignored (Carlton, 1987). Although the societal determinants of differences in the health and mental health care systems must be acknowledged, probably the most compelling argument for combining the two fields is the research-based observation that physical disorders have psychological components and that some major mental disorders are at
least in part biologically determined (Broskowski, 1981; Carlton, 1987). Moreover, utilization studies indicate that the majority of individuals suffering from a mental disorder receive services in the primary health care sector, rather than in the specialty mental health sector (Broskowski, 1981). Using the National Association of Social Workers' (NASW) definition of public health social work services as involving "activities which include prevention, diagnosis, treatment, maintenance and rehabilitation . . . provided in a variety of settings such as: public health programs, general and specialty hospitals, community health centers, community mental health centers and hospices" (Leukefeld, 1985, p. 2), Leukefeld estimated that nearly half the membership of NASW is engaged in public health social work practice and that at least 8,000 students are in public health social work training. Nevertheless, the majority of these social workers do not identify themselves as public health social workers, and it appears that lack of understanding of the nature of public health social work practice is a barrier to incorporating public health concepts in social work education. These findings support the need for prevention training at multiple levels, including the continuing education of practitioners. The tension between proponents of microversus macrolevel practice is another barrier to incorporating a preventive perspective, which requires that social workers intervene at multiple levels simultaneously (Siefert, 1983, 1986). A detailed review of the micro-macro debate is beyond the scope of this article, but Watkins (1985) observed that the tendency of schools of social work to "track" students into micro- or macromethods results in students being proficient in only one method of intervention. Watkins stated that this is not adequate for public health'social work practice, which requires the ability to advocate and to intervene at the community level as well as to work directly with individuals and families. Similarly, Kumabe (1985) noted that the trend toward specialization tends to impede an integrative approach and "perpetuates dichotomous thinking, implying that a different set of knowledge and skins is involved" (p. 136). Again, this supports the need
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for public health social work training in doctoral programs, as well as at the master's and continuing education levels, because doctoral programs produce the faculty who in turn shape curricula. Implementing the Public Health Social Work Forward Plan is a formidable but exciting challenge that demands ongoing and innovative efforts. It is the authors' hope that the project described here will stimulate other such efforts to incorporate increased content from public health in social work education and practice. About the Authors
Kristine Siefert, PhD, MPH, is Associate Professor, and Srinika Jayaratne, PhD, is Professor, School of Social Work, University of Michigan, 1065 Frieze Building, Ann Arbor, MI 48109. Louise Doss Martin, MA, ACSW, is Captain, U.S. Public Health Service, National Health Service Corps, Rockville, MD. An earlier version of this paper was presented at the American Public Health Association Annual Meeting, Boston, November 15, 1988. This paper was coauthored by Louise Doss Martin in her private capacity. No official support or endorsement by the U.S. Department of Health and Human Services, Health Resources and Services Administration, or the Public Health Service is intended or should be inferred. The preparation of this paper was supported in part by NIMH Grant STC-9-5-T24-MH18773. References
Albee, G. W. (1980). The fourth mental health revolution. Journal of Prevention, 1, 67-70. Black, R. B. (1985). The state of the art in public health social work education. In A. Gitterman, R. B. Black, & F. Stein (Eds.), Public health social work in maternal and child health: A forward plan
(pp. 159-165). Rockville, MD: Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services. Bloom, B. L. (1982). Advances and obstacles in prevention of mental disorders. In H. C. Schulberg & M. Killilea (Eds.), Principles and 26
practices of community mental health (pp. 126-
147). San Francisco: Jossey-Bass. Bloom, M., Brown, A., Collins, P., Jayaratne, S., & Siefert, K. (1988, March 7). The Michigan Prevention Training and Curriculum Development Project: Preventive intervention in social work. Pa-
per presented at the Council on Social Work Education Annual Program Meeting, Atlanta. Broskowski, A. (1981). The health-mental health connection. In A. Broskowski, E. Marks, & S. H. Budman (Eds.), Linking health and mental health (pp. 13-25). Beverly Hills, CA: Sage. Carlton, T. 0. (1987). Health/mental health: One field of practice or two? Health and Social Work, 12, 243-245. Caroff, P., & Mailick, M. (1985). Health concentrations in schools of social work: The state of the art. Health and Social Work, 10, 5-14. Gitterman, A., Black, R. B., & Stein, F. (Eds.). (1985). Public health social work in maternal and child health: A forward plan. Rockville, MD: Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services. Green, L. W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education planning. Palo Alto, CA: Mayfield. Jayaratne, S., & Siefert, K. (1987, March 8). Developing a research-based prevention curriculum. Paper presented at the Council on Social Work Education Annual Program Meeting, St. Louis. Jayaratne, S., & Siefert, K. (1989). Clinical training in prevention: Michigan model. Unpublished manuscript, University of Michigan, Ann Arbor. Kumabe, K. (1985). Knowledge and skill requirements for social work practice in maternal and child health. In A. Gitterman, R. B. Black, & F. Stein (Eds.), Public health social work in maternal and child health: A forward plan (pp. 133-147). Rockville, MD: Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services. Leukefeld, C. (1985, October). Public health social workers—who are we? American Public Health Association Social Work Section Newsletter,
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Lorion, R. (1983). Research issues in the design and evaluation of preventive interventions. In J. Bowker (Ed.), Education for primary prevention in social work (pp. 7-23). New York: Council on Social Work Education. Price, R. H. (1982). Priorities for prevention research: Linking risk factor and interuention research. Washington, DC: National Institute of Mental Health, Center for Studies of Prevention. Price, R. H., Cowen, E. L., Lorion, R. P., & RamosMcKay, J. (1989). The search for effective prevention programs: What we learned along the way. American Journ al of Orthopsychiatr y, 59, 49-58. Siefert, K. (1983). Using concepts from epidemiology to teach prevention. In J. Bowker (Ed.), Education for primary prevention in social work (pp. 54-74). NewYork: Council on Social Work Education. Siefert, K. (1986). Theoretical base for social work interventions. In E. Watkins (Ed.), Infant mormorbidity and childhood handicapping condi,
tions: Psychosocial factors (pp. 19-27). Rockville, MD: Bureau of Health Care Delivery and Assistance, Division of Maternal and Child Health, U.S. Department of Health and Human Services. Siefert, K., Martin, L. D., & Jayaratne, S. (1988, November 15). Implementing the Public Health Social Work Forward Plan: A research-based prevention curriculum for schools of social work. Paper presented to the American Public Health Association Annual Meeting, Boston. Watkins, E. (1985). The conceptual base for public health social work. In A. Gitterman, R. B. Black, & F. Stein (Eds.), Public health social work in maternal and child health: A forward plan (pp. 17-33). Rockville, MD: Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services. Accepted June 12, 1990
Social Support Systems in Practice A Generalist Approach by Lambert Maguire Social Support Systems in Practice shows social workers how to use social support systems with cognifive, psychodynamic, problem-solving, and task-centered interventions. It integrates evolving case management, networking, and self-help efforts and focuses on developing a better understanding of natural support systems.
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IMPLEMENTING THE PUBLIC HEALTH SOCIAL WORK FORWARD PLAN
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