The Journal of PrimaryPrevention, Vol. 15, No. 1, 1994
Prevention Science and Practice: An Agenda for Action S t e v e n P. S c h i n k e t
This paper reflects on relevant theories, target populations, channels, interventions, and evaluation methods for prevention within the social and behavioral sciences. After summarizing progress to date in these areas, the paper considers challenges to prevention researchers and practitioners that must be met to continue advances in the field. KEY WORDS: Prevention theory; methods; interventions;evaluationprocedures. Prevention science and practice have grown in sophistication, influence, and application concurrent with and partly due to the publication of the Journal of Primary Prevention. Advances in the young field of prevention in the behavioral and social sciences over the past 15 years are manifold and impressive. Recognition of the value and effectiveness of prevention has come from the public sector in the form of increased funding and support for prevention programs, from the scientific community in the form of national conferences and awards related to prevention, and from academics in the form of courses, dissertations, and books and journal articles on salient topics of prevention science and practice. Despite these incontrovertible gains, much remains to be done to continue the progress of prevention as a legitimate and powerful field of science and practice. This article considers the current state of prevention respective to theories, target populations, channels, interventions, and evaluation methods within the social and behavioral sciences. Against the backdrop of progress to date, the paper reviews challenges that investigators and practitioners must address to advance the field and to meet the needs of the communities, clients, and constituencies we serve. 1Requests for reprints should be directed to Steven Schinke, Columbia University School of Social Work, 622 W e s t 113th Street, New York, NY 10025. 45 9 1994 Human Sciences Press, Inc.
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THEORY Over the course of the past 15 years, several theories have informed prevention science and practice. The most popular of these are social learning theory (Bandura, 1977, 1986), the health belief model (Becker, 1974), the theory of reasoned action (Fishbein, 1979), decision making theory (Janis & Mann, 1977), and problem behavior theory (Jessor, 1984). Guided by these theories and the paradigms that they represent, prevention studies and programs have born fruit in several areas of social and health behavior (Botvin, Schinke, & Orlandi, 1989; Hechinger, 1992; Jason & Rhodes, 1989; Schinke & Gilchrist, 1984a, 1984b). The dated nature of extant theories, however, together with their lack of emphasis on explaining and predicting preventive behavior and action, render many of them limited in their application to the development, implementation, and testing of prevention programs. New and more relevant theories for prevention science and practice are needed. One promising direction for new theories to direct prevention research and programs is provided by work on the manner through which people progressively act to change their own behavior. A contemporary theory that sheds light on how people consider, effect, and maintain personal behavior modification is the stages of change theory. As put forth by Prochaska and his associates DiClemente (Prochaska & DiClemente, I983, 1984, 1986; Prochaska, DiClemente, & Norcross, 1992), stages of change theory is most applicable to the treatment and control of behavior. Yet stages of change theory also has implications for prevention. This theory posits that individuals move through stages of increasing readiness to change their behavior and that interventions should coincide with those stages. Prochaska and his colleagues identify four stages in an individual's readiness to change over a subsequent six-month time period. These stages are: precontemplation, meaning that the individual has no intention to change over the next six months; contemplation, meaning that the individual is strongly considering change in the next six months; action, meaning that the individual is currently actively engaging in efforts to change; and maintenance, meaning that the individual continues to engage in change for at least six months after successfully adopting a new behavior. Stages of change theory can inform prevention research and programs by helping to target preventive efforts. Redefining stages of change within a prevention context, for example, could allow investigators and service providers to address more effectively the readiness for change manifested by an individual or by a group of individuals. Clearly, just as in a treatment
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context, a preventive intervention that responds to contextual variables will have a greater likelihood of success than a less responsive intervention. Stages of change theory thus offers a common language for the design, implementation, and evaluation of prevention programs to speed the development of the field. Peer cluster theory is another useful paradigm to guide prevention research and programs. This theory assumes that peer interactions largely determine risk taking behavior (Oetting & Beauvais, 1986). Peer clusters include interactions among friends, dating dyads, family constellations, and within neighborhood settings, sports teams, and clubs. According to theorists, peer clusters not only account for the presence and type of risk taking among adolescents but may also help youths reduce pressures and influences toward deviance (Oetting & Beauvais, in press). The therapeutic use of peer clusters in an intervention context may enhance efforts to reduce adolescents' risks of cancer-associated life-style behaviors. By providing positive alternatives and by changing social norms, therapeutic peer clusters can be a source of social development.
TARGET POPULATIONS The target populations of prevention research and programs have only in recent years gained interest. Early prevention efforts were based on the assumption that all members of a given population needed intervention and stood to benefit equally from a prevention program. Consequently, preventive interventions were often delivered to every person enrolled in a participating program--e.g., all students, clients, or patients in a social agency, school, classroom, clinic--regardless of each person's demonstrable risk for the behaviors targeted by the preventive intervention. As a result, early prevention programs frequently reached persons not necessarily at risk for the target behavior and failed to discriminate among those at varying levels of risk. Such unfocused efforts wasted prevention resources by intervening with low-risk individuals and failing to address the particular needs of persons at highest risk. Recent efforts have begun to sharpen the focus of prevention targeting. Beginning with a paper by Gordon (1983) that defined public-health prevention efforts according to the level of risk for the target behavior, many prevention programs took the varying degrees of risk into account in setting the level of intervention delivery. For example, such large-scale problems as public safety were addressed by public service announcements broadcast throughout the mass media. Problems like child malnutrition in smaller high-risk groups were addressed by individually aimed p r o g r a m s - -
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public health nurses, for example, reaching out to poor mothers in public housing developments. This tailoring of prevention efforts to the size of populations they serve is sound practice, but even greater investment is needed in order to target prevention research and programs at specific populations according to risk. Increasingly, relevant epidemiological data indicate that major targets for prevention--alcohol and drug abuse, damaging health behavior, and family violence, to name a f e w - - o c c u r at disproportionately high rates among members of certain populations (Bailey, 1992; Walker, Downey, & Nightingale, 1989; Neighbors & LaViest, 1989; Schoenborn & Benson, 1988; Walter, Vaughan, Gladis, Ragin, Kasen, & Cohali, 1992). That these high-risk populations are identifiable is in itself enough to warrant targeted prevention programs. Added support for such targeting comes from intervention outcome showing the relative efficacy of prevention efforts expressly tailored for high-risk populations (Dusenbury, Kerner, Baker, Botvin, James-Ortiz, & Zauber, 1992; Schinke, Orlandi, Forgey, Rugg, & Douglas, 1992). Based on current research knowledge, therefore, sufficient data exist to justify prevention programs that are aimed at and designed for designated high-risk populations. Gender differences too need to be considered when targeting prevention programs (Swift, 1991). Research on smoking prevention, for example, has assumed that the developmental pathways leading to cigarette use are the same for males and females. Recent work, however, suggests that this assumption is false (Gilchrist, Schinke, & Nurius, 1989). For instance, relative to young men, young women may require less emphasis on refusal and other social skills training, more emphasis on avenues for selfdefinition and self-expression that do not rely on smoking, and more help with tension reduction and affect control techniques. Also, women report a preference for interacting and learning in settings that involve close, informal, personal, dyadic, or small group interactions (Mantell, Schinke, & Akabas, 1988). Such specific information on target populations for prevention may lead to interventions that are substantially more efficient and more effective (Adams, Noble & Howard, 1990).
CHANNELS Most of the prevention programs developed over the past two decades approached intervention delivered through one or more of the traditional triad of channels. These three channels are the host, agent, and environment (Schinke and Gilchrist, 1984). Early in the development of prevention as a science, these three channels satisfactorily encompassed the
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loci and venues for problem behavior and its prevention. But as the field has grown in sophistication and in its theoretical and empirical knowledge base, the simple categorization of prevention channels as the host (or person), the agent (or prevention target), and the environment (or social context surrounding the host), offers limited guidance for interventions and their deliveries. Increasingly, investigators are turning to more complex models of channels for prevention (Caplan, 1989). These models point up the salience of using multiple channels both to discover the epidemiology of objectives for prevention efforts and to deliver preventive interventions. One such model notes the importance of biopsychosocial influences on people and their behavior. By recognizing the contributions of biology (including genetics and other organismic variables), of psychology (including personality and other cognitive factors), and of social influences (including one's social milieu and peer networks), the biopsychosocial model goes beyond earlier conventions of the host (Hennessy, 1991). In the biopsychosocial model, the host is viewed as the product of several concurrent forces that may at times offset one another's influence and at other times may join to compound the influences on behavior. The biopsychosocial model, for example, suggests that the offspring of a parent who has a substance abuse problem may face multiple sources of influence toward encountering substance abuse problems later in life. These sources can include a genetic predisposition, certain child rearing practices, and the family norms governing the availability and use of substances. Although not all variables in the biopsychosocial assessment are amenable to change, a comprehensive understanding of the model affords the prevention practitioner greater precision in targeting salient and potentially powerful influences in the client's life, so that prevention resources need not be expended on irrelevant influences. Biopsychosocial models of the etiology of problem behavior and of interventions for preventing problem behavior also bring to light the importance of family and multicultural influences. In the areas of family and multicultural strategies for prevention, the science and practice of our field has burgeoned in recent years (Denollet, 1993). Family influences are evident in the need for preventive interventions, as noted in earlier discussions of risk-based models for the targets of prevention, and in the aforementioned material on biopsychosocial models. But family models may have even greater value as channels for preventive interventions (Bouchard & Drapeau, 1991). Youth-oriented programs, for example, often increase their efficacy in preventing the onset of problem behavior when they engage family members in the intervention process. Expectedly, any intervention that involves families
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will have a greater likelihood of transferring into a youths' everyday reality than will an intervention that involves the youth alone (Roosa, Gensheimer, Ayers, & Short, 1990). Beyond such common sense reasons for engaging family members, however, little is known about ways to galvanize family members into preventive action in a predictably effective manner (Kline, Grayson, & Mathie, 1990; Morgan, Nu'ManSheppard, & Allin, 1990). Greater research attention is needed in order to understand and marshal family resources as a channel for prevention action. As the science of alcohol and other drug abuse prevention has emerged and developed, investigators have devoted increasing attention as well to issues of cultural sensitivity. That attention is due, in part, to the realization that the frequency of alcohol and other drug abuse problems varies measurably between different cultural contexts (Schinke, Botvin, & Orlandi, 1991). Thus, researchers are increasingly tailoring alcohol and other drug abuse prevention programs for the community, or other context, in which it is delivered. T h e i n c l u s i o n o f c u l t u r a l f a c t o r s in p r o g r a m p l a n n i n g , implementation, and evaluation represents a significant dimension of prevention science and practice to emerge in recent years (Dumas, 1989). To be sure, cultural factors were always included in prevention research programs to some degree. But only recently have investigators begun to develop an understanding of how essential these factors are to a successful prevention outcome (Orlandi, 1992; Work, Cowen, Parker, & Wyman, 1990). In the past, investigators were comfortable delivering one universal intervention to all subjects regardless of race, ethnicity, or gender. Today, investigators and practitioners design interventions exclusively for certain groups of people. More importantly, program planners increasingly include members of target groups in the design and implementation of a prevention effort. Ideally, every prevention program should reflect and respect the cultural preferences of the target group. Culture, in the present context, refers to the behaviors and beliefs characteristic of a particular social, ethnic, or age group. Accordingly, cultural factors in prevention programming and evaluation include those characteristics that distinguish one sociodemographic group from another. Regardless of their own ethnic-racial background, investigators and practitioners must attend carefully to issues of cultural sensitivity if they wish to conduct culturally competent prevention programs and studies. Investigators and clinicians cannot assume cultural sensitivity because they have the same cultural background as the target group.
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Shared cultural identity does not guarantee a facility with that culture's day-to-day realities. Depending on geographic origin, income levels, acculturation, religion, and so on, considerable diversity exists among ethnic-racial groups. Thus, the target group will not presume cultural sensitivity from a group of investigators who share their cultural background; rather, investigators and practitioners must demonstrate their cultural sensitivity. Prevention program planners who are from a wholly different culture are particularly challenged in establishing cultural sensitivity. Yet, moving across cultures, or cross-cultural research, is practically unavoidable when designing prevention programs and conducting research. In the United States, preventionists are destined to work with widely varying groups of people. Moreover, significant heterogeneity exists within ethnic-racial groups. In New York City, for example, Hispanic-American means, in order of the proportion of the population represented, Puerto-Rican, Dominican, Cuban, South-American, and Mexican-American. These groups differ greatly from one another, and culturally competent professionals who are developing prevention programs will address each group with these variations in mind. As a reward for such efforts, researchers and clinicians may well find that their prevention programs are not only embraced more warmly by members of the target culture, but are also predictably more effective in achieving the target outcomes. A final channel issue that is germane to the science and practice of prevention is interdisciplinary work. Despite calls for increased interdisciplinary research and practice in the prevention field, the bulk of advances in most areas of the field have been contributed by individuals or teams working within one or two disciplines (Weissman, 1991). Admittedly, joint efforts are difficult across the social, behavioral, and biological sciences. Within each area of science, however, cross-disciplinary work should be relatively easy. For example, a collaboration between social workers, psychologists, and educators seems natural within the context of a clinic or school setting. Yet these collaborations are rare. Inherent barriers persist to impede the development, implementation, and evaluation of prevention programs across disciplines. Such barriers include the unidisciplinary perspective that many professions evince relative to prevention. Theories, methods, and intervention approaches all appear to be more parochial than collaborative in the prevention field (Gilbert, 1982; Cheetman, 1992). That parochialism is very likely due to the training that preventionists receive in their graduate programs and later in continuing education offerings. And too, parochialism is not discouraged in clinical work, in the production and consumption of the professional literature, or in grant development efforts.
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But to move the field forward at the speed necessary to keep pace with the challenges facing prevention in the next 15 years, prevention researchers and practitioners in the various disciplines must collaborate. Only by working across disciplines and professions can we gain adequate understanding of the problems and potential solutions in the prevention field. Indeed, some of the most vexing problems in the field today can only be understood and addressed through interdisciplinary work (Goldstein, 1989). What is more, that work must not only cross disciplines within an area of science (e.g., social, behavioral, biomedical), but must also cross those scientific fields. The target of preventing drug abuse is an example. To gain a complete epidemiological grasp of drug abuse, data are needed from genetics, psychology, social work, and, in the case of youth, education. Because most other refractory problems and pressing issues in the prevention field demand the same level and depth of attention, understanding, and intervention, increased cross-disciplinary work in prevention is timely and needed.
INTERVENTIONS Arguably, the area in which most progress has been made in the prevention field since its inception has been in heightening the sophistication and effectiveness of intervention approaches. Beginning with rather unidimensional and often unfocused intervention strategies, prevention programs have now largely progressed to multifaceted and precisely aimed efforts (Flay, 1985; Perry, Kelder, Murray, & Klepp, 1992). Still, more work is needed to develop preventive interventions that help people avoid altogether the onset of problems and problem-behavior patterns. That work will wisely start by building on current knowledge about effective preventive interventions. Such knowledge indicates that interventions will increase their impact by focusing on relatively few target behaviors, by using multiple venues for intervention delivery (e.g., school, community, media), and by providing ongoing contact with program participants for as long as possible (e.g., through booster sessions). From this knowledge base, investigators and practitioners can continue to invest in building new and improved intervention modules. Those models will profitably draw upon extant information to design strategies that recognize the confluence of factors that can lead people toward problem behavior. For instance, by using epidemiological data to direct the intervention development process, researchers and program planners can design prevention strategies that have a likelihood of responding to known influences on specific target behaviors. Further, any new intervention approach should be launched upon the empirical base laid
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by past prevention programs outcome studies. In so doing, new preventive interventions will planfully, yet aggressively push the field forward.
EVALUATION METHODS The evaluation of prevention programs is of clear importance to the field's advancement. Fortunately, many and varied methods exist to evaluate not only the outcomes, but also the processes of prevention programs. These methods have been steadily increasing in number in recent years, with a resulting increase in the standards for isolating the impact of prevention efforts (Dumas, 1989). Still, challenges remain to the comprehensive evaluation of preventive intervention programs. One of the greatest concerns the means by which the changes brought about by prevention programs are to be measured. By definition, prevention programs aim to decrease the incidence and prevalence of problems that will arise in the future. The true impact of a prevention effort, as such, may thus not be observable for many years after the initiation of the program. But resource constraints, together with the difficulties of sustaining contact with program participants, preclude the conduct of the longitudinal follow-up studies necessary for the documentation of prevention program effects. Added to these obstacles are the interpretation issues inherent in inferring that a prevention program long since delivered is responsible for effects seen many years later. Another challenge confronting prevention research is the need for flexible methodologies suited to the realities of applied settings. When program planners carry out prevention efforts in clinics, schools, and other human services contexts, the demands of the applied setting must rightfully take priority over the needs of evaluation research. Yet, without having access to empirical outcome data on a program's impact and without qualitative and quantitative process evaluation data, program planners cannot make reasoned decisions about the value of a program. Consequently, better methods are needed for evaluating prevention programs in applied settings (Schinke, Gilchrist, Lodish, & Bobo, 1983). Other challenges facing the evaluation of prevention programs encompass methodological issues that may not affect the bulk of applied programs, but that do influence the type of academic research that can serve to move the field forward. These issues concern the appropriate unit of assignment and analysis for prevention studies with intact populations, such as youths in schools, the verification of self-reported behavior change, and the sensitivity of psychological measures to outcomes of prevention programs (cf. Murray et al., 1993).
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The time is now at hand to expand upon and improve evaluations for prevention science and practice. Only through the use of a consistent, rigorously applied set of evaluation methods can prevention researchers and practitioners determine empirically the effects of prevention programs. The use of evaluation methods must accordingly be viewed as integral to the development of the prevention field.
SUMMARY This article has described briefly the current state of prevention science and practice and has outlined an agenda for the future advancement of the field. In so doing, the paper has limited its discussion to issues of theory, target populations, channels, interventions, and evaluation methods for prevention within the social and behavioral sciences. When one reflects on the field of prevention in the 15 years since the inauguration of this journal and the nearly three decades that have passed since the publication of Caplan's (1964) ground-breaking book, Principles of Preventive Psychiatry, it becomes clear that considerable progress has been made in the five areas discussed in the present review. Yet much work lies ahead before prevention science and practice are viewed as legitimate fields of inquiry and service delivery within the scientific and clinical communities. Indeed, the burden on prevention investigators and practitioners to demonstrate and prove the value of their efforts has stepped up in recent years and promises to increase further. As prevention becomes more widely practiced and advocated, the greater will become the degree of public visibility and, hence, scrutiny. At risk to their credibility and funding base, overzealous advocates run the risk of hailing prevention programs as panaceas for the ills of society. Arguably, prevention offers the only viable option for many life-threatening problems (cf. Coates, 1993). Nonetheless, prevention programs have failed to live up to their promise in important areas that affect children, youth, and adults. Prevention today, therefore, has entered a critical period as a science and as a useful and cost-beneficial strategy. The diligent efforts of prevention researchers and practitioners are needed to lead the field through this period and into the coming decades when expectations will increase commensurate to the scope and number of problems we confront. Perhaps the agenda for continuing improvement, self-scrutiny, and change put forth in this paper will in some small way offer a blueprint for that leadership.
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ACKNOWLEDGMENTS Research in this paper was supported by grants from the New York State Office of Alcoholism and Substance Abuse Services, the National Institute on Drug Abuse (DA0532 1), and the National Cancer Institute (CA52279). Portions of this paper were presented at the meeting of the Society for Prevention Research held in Lexington, Kentucky, October 20-23, 1993.
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Gordon, R. S., Jr. (1983). An operational classification of disease prevention. Public Health Reports, 98, 107-109. Hechinger, F. M. (1992). Fateful choices: Healthy youth for the 21st century. New York: Carnegie Corporation. Hennessy, M. (1991). Designing and evaluating alcohol problem community interventions: Quasi-lessons from the experience of medical trials. Journal of Primary Prevention, 1L 169-192. Hiatt, R. A., Klatsky, A. L., & Armstrong, M. A. (1988). Alcohol consumption and the risk of breast cancer in a prepaid health plan. Cancer Research, 48, 2284-2287. Janis, L L., & Mann, L. (1977). Decision-making. A psychological analysis of conflict, choice, and commitment. New York: Free Press. Jason, L. A., & Rhodes, J. (1989). Children helping children: implications for prevention. Journal of Primary Prevention, 9, 203-212. Jessor, R. (1984). Adolescent development and behavioral hea~th. In J. D. Matarazzo, S. M. Weiss, J. A. erd, N. E. Miller, & S. M. Weiss (Eds.), Behavioral health (pp. 69-90). New York: John Wiley. Kline, B., Grayson, J., & Mathie, V. (1990). Parenting support groups for parents at risk of abuse and neglect. Journal of Primary Prevention, 10, 313-320. Mantell, J. E., Schinke, S. P., & Akabas, S. H. (1988). Women and AIDS prevention. Journal of Primary Prevention, 9, 18-40. Morgan, J. R., Nu'Man-Sheppard, J., & Allin, D. W. (1990). Prevention through parent training: Three preventive parent education programs. Journal of Primary Prevention, 10, 321-332. Murray, D. M., Rooney, B. L., Hannan, P. J., Peterson, A., Ary, D. V., Futterman, R., Biglan, R., Botvin, G. J., Evans, R. I., Flay, B. R., Getz, J. G., Marek, P. M., Orlandi, M., Pentz, M. A., Perry, C. L., & Schinke, S. P. (1993). Intraclass correlation among common measures of adolescent smoking: Estimates, correlates and applications in smoking prevention studies. Unpublished manuscript. University of Minnesota, Division of Epidemiology, School of Public Health. Neighbors, H. W., & LaViest, T. A. (1989). Socioeconomic status and psychological distress: The impact of financial aid on economic problem severity. Journal of Primary Prevention, 10, 149-165. Oetting, E., & Beauvais, F. (1986). Peer cluster theory: Drugs and the adolescent. Journal of Counseling Development, 65, 17-22. Oetting, E., & Beauvais, F. (in press). Peer cluster theory, socialization characteristics and adolescent drug use: A path analysis. Journal of Counseling Psychology. Perry, C. L-, Kelder, S. H., Murray D. M., & Klepp K. I. (1992). Community wide smoking prevention: Long-term outcomes of the Minnesota heart health program and the class of 1989 study. American Journal of Public Health, 82, 1210-1216. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5L 390-395. Prochaska, J. O., & Diclemente, C. C. (1984). The trans theoretical approach: Crossing the traditional boundaries of therapy. Homewood, Illinois: Dow-Jones/Irwin. Prochaska, J. O., & DiC|emente, C. C. (1986). Toward a comprehensive model of change. In W. Miller and N. Heather (Eds.), Treating addictive behaviors (pp. 3-27). New York: Plenum Press. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to the addictive behaviors. American Psychologist, 47, 1102-1114. Roosa, M. W., Gensheimer, L. K., Ayers, T. S., & Short, J. L. (1990). Development of a school-based prevention program for children in alcoholic families. Journal of Primary Prevention, 11, 119-141. Schinke, S. P., Botvin, G. J., & Orlandi, M. A- (1991). Substance abuse in children and adolescents. Newbury Park, CA: Sage Publications. Schinke, S. P., & Gilchrist, L. D. (1984a). Life skills counseling with adolescents. Baltimore: University Park Press.
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Schinke, S. P., & Gilchrist, L. D. (1984b). Preventing cigarette smoking with youth. Journal of Primary Prevention, 5, 48-56. Schinke, S. P., Gilchrist, L. D., Lodish, D., & Bobo, J. K. (1983). Strategies for prevention research in service environments. Evaluation Review, 7, 126-136. Schinke, S. P., Orlandi, M. A., Forgey, M. A., Rugg, D. L., & Douglas, K. A. (1992). Multieomponent, school-based strategies to prevent HIV infection and sexually transmitted diseases among adolescents: Theory and research into practice. Research on Social Work Practice, 2, 364-379. Schoenborn, C. A., & Benson, V. (1988). Relationships between smoking and other unhealthy habits: United States, 1985. Advance Data, No. 154, Vital Statistics. Hyattsville, MD: National Center for Health Statistics. Swift, C. F. (1991). Some issues in inter-gender humiliation. Journal of Primary Prevention, 12, 93-122. Walker, E., Downey, G., & Nightingale, N. (1989) The nonorthogonal nature of risk factors: implications for research on the causes of maladjustment. The Journal of Primary Prevention, 9, 143-163. Walter, H. J., Vaughan, R. D., Gladis, M. M., Ragin, D. F., Kasen, S., & Cohall, A. T. (1992). Factors associated with AIDS risk behaviors among high school students in an AIDS epicenter. American Journal of Public Health, 82, 528-532. Weissman, G. (1991). Prevention for women at risk: Experience from a national demonstration research program. Journal of Primary Prevention, 12, 35-48. Work, W. C., Cowen, E. L., Parker, G. R., & Wyman, P. A. (1990). Stress resilient children in urban settings. Journal of Primary Prevention, 11, 3-17.
Prevention Science and Practice: An Agenda for Action S t e v e n P. S c h i n k e t
This paper reflects on relevant theories, target populations, channels, interventions, and evaluation methods for prevention within the social and behavioral sciences. After summarizing progress to date in these areas, the paper considers challenges to prevention researchers and practitioners that must be met to continue advances in the field. KEY WORDS: Prevention theory; methods; interventions;evaluationprocedures. Prevention science and practice have grown in sophistication, influence, and application concurrent with and partly due to the publication of the Journal of Primary Prevention. Advances in the young field of prevention in the behavioral and social sciences over the past 15 years are manifold and impressive. Recognition of the value and effectiveness of prevention has come from the public sector in the form of increased funding and support for prevention programs, from the scientific community in the form of national conferences and awards related to prevention, and from academics in the form of courses, dissertations, and books and journal articles on salient topics of prevention science and practice. Despite these incontrovertible gains, much remains to be done to continue the progress of prevention as a legitimate and powerful field of science and practice. This article considers the current state of prevention respective to theories, target populations, channels, interventions, and evaluation methods within the social and behavioral sciences. Against the backdrop of progress to date, the paper reviews challenges that investigators and practitioners must address to advance the field and to meet the needs of the communities, clients, and constituencies we serve. 1Requests for reprints should be directed to Steven Schinke, Columbia University School of Social Work, 622 W e s t 113th Street, New York, NY 10025. 45 9 1994 Human Sciences Press, Inc.
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THEORY Over the course of the past 15 years, several theories have informed prevention science and practice. The most popular of these are social learning theory (Bandura, 1977, 1986), the health belief model (Becker, 1974), the theory of reasoned action (Fishbein, 1979), decision making theory (Janis & Mann, 1977), and problem behavior theory (Jessor, 1984). Guided by these theories and the paradigms that they represent, prevention studies and programs have born fruit in several areas of social and health behavior (Botvin, Schinke, & Orlandi, 1989; Hechinger, 1992; Jason & Rhodes, 1989; Schinke & Gilchrist, 1984a, 1984b). The dated nature of extant theories, however, together with their lack of emphasis on explaining and predicting preventive behavior and action, render many of them limited in their application to the development, implementation, and testing of prevention programs. New and more relevant theories for prevention science and practice are needed. One promising direction for new theories to direct prevention research and programs is provided by work on the manner through which people progressively act to change their own behavior. A contemporary theory that sheds light on how people consider, effect, and maintain personal behavior modification is the stages of change theory. As put forth by Prochaska and his associates DiClemente (Prochaska & DiClemente, I983, 1984, 1986; Prochaska, DiClemente, & Norcross, 1992), stages of change theory is most applicable to the treatment and control of behavior. Yet stages of change theory also has implications for prevention. This theory posits that individuals move through stages of increasing readiness to change their behavior and that interventions should coincide with those stages. Prochaska and his colleagues identify four stages in an individual's readiness to change over a subsequent six-month time period. These stages are: precontemplation, meaning that the individual has no intention to change over the next six months; contemplation, meaning that the individual is strongly considering change in the next six months; action, meaning that the individual is currently actively engaging in efforts to change; and maintenance, meaning that the individual continues to engage in change for at least six months after successfully adopting a new behavior. Stages of change theory can inform prevention research and programs by helping to target preventive efforts. Redefining stages of change within a prevention context, for example, could allow investigators and service providers to address more effectively the readiness for change manifested by an individual or by a group of individuals. Clearly, just as in a treatment
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context, a preventive intervention that responds to contextual variables will have a greater likelihood of success than a less responsive intervention. Stages of change theory thus offers a common language for the design, implementation, and evaluation of prevention programs to speed the development of the field. Peer cluster theory is another useful paradigm to guide prevention research and programs. This theory assumes that peer interactions largely determine risk taking behavior (Oetting & Beauvais, 1986). Peer clusters include interactions among friends, dating dyads, family constellations, and within neighborhood settings, sports teams, and clubs. According to theorists, peer clusters not only account for the presence and type of risk taking among adolescents but may also help youths reduce pressures and influences toward deviance (Oetting & Beauvais, in press). The therapeutic use of peer clusters in an intervention context may enhance efforts to reduce adolescents' risks of cancer-associated life-style behaviors. By providing positive alternatives and by changing social norms, therapeutic peer clusters can be a source of social development.
TARGET POPULATIONS The target populations of prevention research and programs have only in recent years gained interest. Early prevention efforts were based on the assumption that all members of a given population needed intervention and stood to benefit equally from a prevention program. Consequently, preventive interventions were often delivered to every person enrolled in a participating program--e.g., all students, clients, or patients in a social agency, school, classroom, clinic--regardless of each person's demonstrable risk for the behaviors targeted by the preventive intervention. As a result, early prevention programs frequently reached persons not necessarily at risk for the target behavior and failed to discriminate among those at varying levels of risk. Such unfocused efforts wasted prevention resources by intervening with low-risk individuals and failing to address the particular needs of persons at highest risk. Recent efforts have begun to sharpen the focus of prevention targeting. Beginning with a paper by Gordon (1983) that defined public-health prevention efforts according to the level of risk for the target behavior, many prevention programs took the varying degrees of risk into account in setting the level of intervention delivery. For example, such large-scale problems as public safety were addressed by public service announcements broadcast throughout the mass media. Problems like child malnutrition in smaller high-risk groups were addressed by individually aimed p r o g r a m s - -
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public health nurses, for example, reaching out to poor mothers in public housing developments. This tailoring of prevention efforts to the size of populations they serve is sound practice, but even greater investment is needed in order to target prevention research and programs at specific populations according to risk. Increasingly, relevant epidemiological data indicate that major targets for prevention--alcohol and drug abuse, damaging health behavior, and family violence, to name a f e w - - o c c u r at disproportionately high rates among members of certain populations (Bailey, 1992; Walker, Downey, & Nightingale, 1989; Neighbors & LaViest, 1989; Schoenborn & Benson, 1988; Walter, Vaughan, Gladis, Ragin, Kasen, & Cohali, 1992). That these high-risk populations are identifiable is in itself enough to warrant targeted prevention programs. Added support for such targeting comes from intervention outcome showing the relative efficacy of prevention efforts expressly tailored for high-risk populations (Dusenbury, Kerner, Baker, Botvin, James-Ortiz, & Zauber, 1992; Schinke, Orlandi, Forgey, Rugg, & Douglas, 1992). Based on current research knowledge, therefore, sufficient data exist to justify prevention programs that are aimed at and designed for designated high-risk populations. Gender differences too need to be considered when targeting prevention programs (Swift, 1991). Research on smoking prevention, for example, has assumed that the developmental pathways leading to cigarette use are the same for males and females. Recent work, however, suggests that this assumption is false (Gilchrist, Schinke, & Nurius, 1989). For instance, relative to young men, young women may require less emphasis on refusal and other social skills training, more emphasis on avenues for selfdefinition and self-expression that do not rely on smoking, and more help with tension reduction and affect control techniques. Also, women report a preference for interacting and learning in settings that involve close, informal, personal, dyadic, or small group interactions (Mantell, Schinke, & Akabas, 1988). Such specific information on target populations for prevention may lead to interventions that are substantially more efficient and more effective (Adams, Noble & Howard, 1990).
CHANNELS Most of the prevention programs developed over the past two decades approached intervention delivered through one or more of the traditional triad of channels. These three channels are the host, agent, and environment (Schinke and Gilchrist, 1984). Early in the development of prevention as a science, these three channels satisfactorily encompassed the
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loci and venues for problem behavior and its prevention. But as the field has grown in sophistication and in its theoretical and empirical knowledge base, the simple categorization of prevention channels as the host (or person), the agent (or prevention target), and the environment (or social context surrounding the host), offers limited guidance for interventions and their deliveries. Increasingly, investigators are turning to more complex models of channels for prevention (Caplan, 1989). These models point up the salience of using multiple channels both to discover the epidemiology of objectives for prevention efforts and to deliver preventive interventions. One such model notes the importance of biopsychosocial influences on people and their behavior. By recognizing the contributions of biology (including genetics and other organismic variables), of psychology (including personality and other cognitive factors), and of social influences (including one's social milieu and peer networks), the biopsychosocial model goes beyond earlier conventions of the host (Hennessy, 1991). In the biopsychosocial model, the host is viewed as the product of several concurrent forces that may at times offset one another's influence and at other times may join to compound the influences on behavior. The biopsychosocial model, for example, suggests that the offspring of a parent who has a substance abuse problem may face multiple sources of influence toward encountering substance abuse problems later in life. These sources can include a genetic predisposition, certain child rearing practices, and the family norms governing the availability and use of substances. Although not all variables in the biopsychosocial assessment are amenable to change, a comprehensive understanding of the model affords the prevention practitioner greater precision in targeting salient and potentially powerful influences in the client's life, so that prevention resources need not be expended on irrelevant influences. Biopsychosocial models of the etiology of problem behavior and of interventions for preventing problem behavior also bring to light the importance of family and multicultural influences. In the areas of family and multicultural strategies for prevention, the science and practice of our field has burgeoned in recent years (Denollet, 1993). Family influences are evident in the need for preventive interventions, as noted in earlier discussions of risk-based models for the targets of prevention, and in the aforementioned material on biopsychosocial models. But family models may have even greater value as channels for preventive interventions (Bouchard & Drapeau, 1991). Youth-oriented programs, for example, often increase their efficacy in preventing the onset of problem behavior when they engage family members in the intervention process. Expectedly, any intervention that involves families
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will have a greater likelihood of transferring into a youths' everyday reality than will an intervention that involves the youth alone (Roosa, Gensheimer, Ayers, & Short, 1990). Beyond such common sense reasons for engaging family members, however, little is known about ways to galvanize family members into preventive action in a predictably effective manner (Kline, Grayson, & Mathie, 1990; Morgan, Nu'ManSheppard, & Allin, 1990). Greater research attention is needed in order to understand and marshal family resources as a channel for prevention action. As the science of alcohol and other drug abuse prevention has emerged and developed, investigators have devoted increasing attention as well to issues of cultural sensitivity. That attention is due, in part, to the realization that the frequency of alcohol and other drug abuse problems varies measurably between different cultural contexts (Schinke, Botvin, & Orlandi, 1991). Thus, researchers are increasingly tailoring alcohol and other drug abuse prevention programs for the community, or other context, in which it is delivered. T h e i n c l u s i o n o f c u l t u r a l f a c t o r s in p r o g r a m p l a n n i n g , implementation, and evaluation represents a significant dimension of prevention science and practice to emerge in recent years (Dumas, 1989). To be sure, cultural factors were always included in prevention research programs to some degree. But only recently have investigators begun to develop an understanding of how essential these factors are to a successful prevention outcome (Orlandi, 1992; Work, Cowen, Parker, & Wyman, 1990). In the past, investigators were comfortable delivering one universal intervention to all subjects regardless of race, ethnicity, or gender. Today, investigators and practitioners design interventions exclusively for certain groups of people. More importantly, program planners increasingly include members of target groups in the design and implementation of a prevention effort. Ideally, every prevention program should reflect and respect the cultural preferences of the target group. Culture, in the present context, refers to the behaviors and beliefs characteristic of a particular social, ethnic, or age group. Accordingly, cultural factors in prevention programming and evaluation include those characteristics that distinguish one sociodemographic group from another. Regardless of their own ethnic-racial background, investigators and practitioners must attend carefully to issues of cultural sensitivity if they wish to conduct culturally competent prevention programs and studies. Investigators and clinicians cannot assume cultural sensitivity because they have the same cultural background as the target group.
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Shared cultural identity does not guarantee a facility with that culture's day-to-day realities. Depending on geographic origin, income levels, acculturation, religion, and so on, considerable diversity exists among ethnic-racial groups. Thus, the target group will not presume cultural sensitivity from a group of investigators who share their cultural background; rather, investigators and practitioners must demonstrate their cultural sensitivity. Prevention program planners who are from a wholly different culture are particularly challenged in establishing cultural sensitivity. Yet, moving across cultures, or cross-cultural research, is practically unavoidable when designing prevention programs and conducting research. In the United States, preventionists are destined to work with widely varying groups of people. Moreover, significant heterogeneity exists within ethnic-racial groups. In New York City, for example, Hispanic-American means, in order of the proportion of the population represented, Puerto-Rican, Dominican, Cuban, South-American, and Mexican-American. These groups differ greatly from one another, and culturally competent professionals who are developing prevention programs will address each group with these variations in mind. As a reward for such efforts, researchers and clinicians may well find that their prevention programs are not only embraced more warmly by members of the target culture, but are also predictably more effective in achieving the target outcomes. A final channel issue that is germane to the science and practice of prevention is interdisciplinary work. Despite calls for increased interdisciplinary research and practice in the prevention field, the bulk of advances in most areas of the field have been contributed by individuals or teams working within one or two disciplines (Weissman, 1991). Admittedly, joint efforts are difficult across the social, behavioral, and biological sciences. Within each area of science, however, cross-disciplinary work should be relatively easy. For example, a collaboration between social workers, psychologists, and educators seems natural within the context of a clinic or school setting. Yet these collaborations are rare. Inherent barriers persist to impede the development, implementation, and evaluation of prevention programs across disciplines. Such barriers include the unidisciplinary perspective that many professions evince relative to prevention. Theories, methods, and intervention approaches all appear to be more parochial than collaborative in the prevention field (Gilbert, 1982; Cheetman, 1992). That parochialism is very likely due to the training that preventionists receive in their graduate programs and later in continuing education offerings. And too, parochialism is not discouraged in clinical work, in the production and consumption of the professional literature, or in grant development efforts.
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But to move the field forward at the speed necessary to keep pace with the challenges facing prevention in the next 15 years, prevention researchers and practitioners in the various disciplines must collaborate. Only by working across disciplines and professions can we gain adequate understanding of the problems and potential solutions in the prevention field. Indeed, some of the most vexing problems in the field today can only be understood and addressed through interdisciplinary work (Goldstein, 1989). What is more, that work must not only cross disciplines within an area of science (e.g., social, behavioral, biomedical), but must also cross those scientific fields. The target of preventing drug abuse is an example. To gain a complete epidemiological grasp of drug abuse, data are needed from genetics, psychology, social work, and, in the case of youth, education. Because most other refractory problems and pressing issues in the prevention field demand the same level and depth of attention, understanding, and intervention, increased cross-disciplinary work in prevention is timely and needed.
INTERVENTIONS Arguably, the area in which most progress has been made in the prevention field since its inception has been in heightening the sophistication and effectiveness of intervention approaches. Beginning with rather unidimensional and often unfocused intervention strategies, prevention programs have now largely progressed to multifaceted and precisely aimed efforts (Flay, 1985; Perry, Kelder, Murray, & Klepp, 1992). Still, more work is needed to develop preventive interventions that help people avoid altogether the onset of problems and problem-behavior patterns. That work will wisely start by building on current knowledge about effective preventive interventions. Such knowledge indicates that interventions will increase their impact by focusing on relatively few target behaviors, by using multiple venues for intervention delivery (e.g., school, community, media), and by providing ongoing contact with program participants for as long as possible (e.g., through booster sessions). From this knowledge base, investigators and practitioners can continue to invest in building new and improved intervention modules. Those models will profitably draw upon extant information to design strategies that recognize the confluence of factors that can lead people toward problem behavior. For instance, by using epidemiological data to direct the intervention development process, researchers and program planners can design prevention strategies that have a likelihood of responding to known influences on specific target behaviors. Further, any new intervention approach should be launched upon the empirical base laid
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by past prevention programs outcome studies. In so doing, new preventive interventions will planfully, yet aggressively push the field forward.
EVALUATION METHODS The evaluation of prevention programs is of clear importance to the field's advancement. Fortunately, many and varied methods exist to evaluate not only the outcomes, but also the processes of prevention programs. These methods have been steadily increasing in number in recent years, with a resulting increase in the standards for isolating the impact of prevention efforts (Dumas, 1989). Still, challenges remain to the comprehensive evaluation of preventive intervention programs. One of the greatest concerns the means by which the changes brought about by prevention programs are to be measured. By definition, prevention programs aim to decrease the incidence and prevalence of problems that will arise in the future. The true impact of a prevention effort, as such, may thus not be observable for many years after the initiation of the program. But resource constraints, together with the difficulties of sustaining contact with program participants, preclude the conduct of the longitudinal follow-up studies necessary for the documentation of prevention program effects. Added to these obstacles are the interpretation issues inherent in inferring that a prevention program long since delivered is responsible for effects seen many years later. Another challenge confronting prevention research is the need for flexible methodologies suited to the realities of applied settings. When program planners carry out prevention efforts in clinics, schools, and other human services contexts, the demands of the applied setting must rightfully take priority over the needs of evaluation research. Yet, without having access to empirical outcome data on a program's impact and without qualitative and quantitative process evaluation data, program planners cannot make reasoned decisions about the value of a program. Consequently, better methods are needed for evaluating prevention programs in applied settings (Schinke, Gilchrist, Lodish, & Bobo, 1983). Other challenges facing the evaluation of prevention programs encompass methodological issues that may not affect the bulk of applied programs, but that do influence the type of academic research that can serve to move the field forward. These issues concern the appropriate unit of assignment and analysis for prevention studies with intact populations, such as youths in schools, the verification of self-reported behavior change, and the sensitivity of psychological measures to outcomes of prevention programs (cf. Murray et al., 1993).
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The time is now at hand to expand upon and improve evaluations for prevention science and practice. Only through the use of a consistent, rigorously applied set of evaluation methods can prevention researchers and practitioners determine empirically the effects of prevention programs. The use of evaluation methods must accordingly be viewed as integral to the development of the prevention field.
SUMMARY This article has described briefly the current state of prevention science and practice and has outlined an agenda for the future advancement of the field. In so doing, the paper has limited its discussion to issues of theory, target populations, channels, interventions, and evaluation methods for prevention within the social and behavioral sciences. When one reflects on the field of prevention in the 15 years since the inauguration of this journal and the nearly three decades that have passed since the publication of Caplan's (1964) ground-breaking book, Principles of Preventive Psychiatry, it becomes clear that considerable progress has been made in the five areas discussed in the present review. Yet much work lies ahead before prevention science and practice are viewed as legitimate fields of inquiry and service delivery within the scientific and clinical communities. Indeed, the burden on prevention investigators and practitioners to demonstrate and prove the value of their efforts has stepped up in recent years and promises to increase further. As prevention becomes more widely practiced and advocated, the greater will become the degree of public visibility and, hence, scrutiny. At risk to their credibility and funding base, overzealous advocates run the risk of hailing prevention programs as panaceas for the ills of society. Arguably, prevention offers the only viable option for many life-threatening problems (cf. Coates, 1993). Nonetheless, prevention programs have failed to live up to their promise in important areas that affect children, youth, and adults. Prevention today, therefore, has entered a critical period as a science and as a useful and cost-beneficial strategy. The diligent efforts of prevention researchers and practitioners are needed to lead the field through this period and into the coming decades when expectations will increase commensurate to the scope and number of problems we confront. Perhaps the agenda for continuing improvement, self-scrutiny, and change put forth in this paper will in some small way offer a blueprint for that leadership.
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ACKNOWLEDGMENTS Research in this paper was supported by grants from the New York State Office of Alcoholism and Substance Abuse Services, the National Institute on Drug Abuse (DA0532 1), and the National Cancer Institute (CA52279). Portions of this paper were presented at the meeting of the Society for Prevention Research held in Lexington, Kentucky, October 20-23, 1993.
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