The Journal of Primary Prevention, Vol. 15, No, 1, 1994
The What, Who, Why, Where, When, and How of Primary Prevention T h o m a s P. G u l l o t t a I
This paper discusses primary prevention's basic tenets and generic principles. It describes its essential elements and explains how prevention's technology of education, social competency, community organization~systems intervention, and natural caregiving can be used to prevent dysfunctional behaviors while promoting healthy lifestyles. KEY W O R D S : Primary prevention; prevention's technology; understanding primary
prevention.
In the Spring of 1993, I had the opportunity to participate on an advisory panel for the Center for Substance Abuse Prevention. Drawn from several professional organizations, panel members spent three difficult days attempting to advise a group of contractors on the development of prevention curriculums for disciplines like social work, nursing, dentistry, community health center staff, and rehabilitation specialists. I use the word difficult intentionally because few of the panel members could agree on even a common definition for primary prevention. Rather, hindered by the limitations of our educational paradigms and world experiences, each of us defined prevention to generally encompass current work activities. I had a similar but briefer experience several months later at a National Institute of Health conference. Billed as, "Disease Prevention Research At NIH: An Agenda For All," I had the sensation that NIH's much trumpeted decade of the brain was being repackaged into the more currently and politically correct language of prevention. These recent experiences serve as the motivation for undertaking this article. It is an lDirect all inquiries to Thomas P. Gullotta, Child and Family Agency, 255 Hempstead Street, New London, CT. 06320.
9 1994Human SciencesPress, Inc.
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Gullota
attempt to describe primary prevention in a way not belonging to any one discipline or field. It is an attempt to discuss primary prevention in a manner that illustrates its basic tenets and principles. What is Primary Prevention?
Primary prevention can be defined as planned efforts to reduce (prevenO the incidence of new cases of dysfunctional behavior in a population not yet demonstrafing signs of dysfunctional behavior and to encourage (promote) behaviors that are known to contribute to functional behaviors. This definition avoids using words like illness and health, although in latter paragraphs I will use these and other words interchangeably with functional and dysfunctional behavior. Words like illness or health frequently can be construed to imply a biological origin for behavior. While I will not deny that some dysfunctional behaviors may contain a biological component, most do not. And even those behaviors that have attracted the greatest biological interest (alcoholism and depression) still remain elusive targets for the geneticists who even in the best of their imperfect studies must continue to attribute one-half or more of the variance to environmental variables (see Holden, 1987, 1991; Peele, 1986; Plomin, 1990). Rather dysfunctional behaviors are most often the result of flawed interpersonal or person to society relationships (Albee, 1983, 1987). Who is the Focus of Primary Prevention Activities?
Primary prevention focuses on healthy populations. The why of the who can be found in the what of primary prevention. That is, primary prevention is concerned with reducing the incidence of new cases of dysfunctional behavior in a society while encouraging lifestyles that encourage functional behaviors in society. Treatment is not prevention. Rehabilitation is not prevention. Does this mean that recently brain injuries individuals may not benefit from primary prevention initiatives? Certainly not. If the initiative is to promote understanding and the acceptance of individuals with disabilities in the wider society, then this is a most appropriate population with whom to be involved. If the initiative is a group focused set of activities (involving education, competency promotion, self-help, and community change) to prevent the clinical depression that frequently follows serious injuries of this nature, then this is, again, a most appropriate population with whom to be involved. Incidentally, in the first example note that it is the general public that is the target for changed behavior.
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A n o t h e r w h o p o i n t is f o u n d in the w o r d "society". F o r m e n t a l health, public health, and o t h e r professional helping disciplines, prev e n t i o n is group not individually focused (Klein and G o l d s t o n , 1977). T h e s e proactive p o p u l a t i o n efforts u n d e r t a k e n by professional helping disciplines are i n t e n d e d to e n c o u r a g e o t h e r s to act on an individual basis to p r o m o t e functional behaviors. By equipping teachers, clergy, y o u t h leaders, b a r t e n d e r s , hairdressers, media r e p o r t e r s , students, parents, friends, and others with the ability, skills, and knowledge to prom o t e f u n c t i o n a l b e h a v i o r s in t h e m s e l v e s a n d o t h e r s , p r e v e n t i o n happens. F r o m the symbolic interactionist perspective, it is w h e n mental health professionals exchange their roles as clinicians for o t h e r roles like parent, spouse, friend, or y o u t h leader, that they have the o p p o r tunity (acting as private citizens) to p r o m o t e functional behaviors for themselves and others. Incidentally, to revisit the earlier example of the recently brain injured individual, all of the aforementioned prevention educated groups would have encouraged the behavior that wearing a helmet while riding a bike, horse, motorcycle, or skate board was a wise and sensible act to practice. T o avoid a disabling brain injury is preferable to either preventing the subsequent depression that frequently follows such an injury or promoting the societal acceptance of individuals who have experienced such an unfortunate occurrence.
Why is P r i m a r y Prevention Necessary?
Primary prevention makes sense. That is dollar "cents" and wellness sense. F r o m the old adage that an ounce of prevention is worth a pound of cure to the reality that American citizens can no longer support the cost of a seemingly ever expanding health care industry mesmerized with high technology, prevention makes sense. As noted earlier, most of the dysfunctional behaviors (illnesses) affecting individuals are lifestyle decisions. These are decisions that can and should be influenced toward more functional (healthier) behaviors. As the National Commission on Children (1991, p. 126-127) noted in their report Beyond Rhetoric: A New American
Agenda for Children and Families: Malnourishment, obesity, and the incidence of many illnesses are related to nutritional intake. Sexuallytransmitted diseases, accidents and injuries, and physical and mental impairments are directly attributable to early, unprotected sexual activity, drug and alcohol use, and delinquent behavior . . . . In fact, better control of a limited number of risk factors . . . could prevent at least 40 percent of all premature deaths, one-third of all short-term disability cases, and two-thirds of all
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chronic disabilitycases. Changes in health behaviors can also reduce medical costs and limit losses in productivity. Illnesses attributable to smoking cost individuals and society more than $65 billion a year. The total cost of alcohol and drug abuse exceeds $110 billion each year. (National Commissionon Children, 1991: p. 126-127) Investing in prevention will not mean the demise of either mental health treatment or rehabilitation services. Indeed, as George Albee (1983, 1985, and Gullotta, 1986) and others (Committee on Preventive Psychiatry, 1980) have pointed out, epidemiological studies suggest that in any given year 15% of the population of the United States are (to use the language of the health care industry) seriously emotionally ill. With an estimated U n i t e d States population of 255,000,000 individuals, this means that roughly 38,250,000 individuals are yearly in need of help. Yet, the treatment and rehabilitation capacity of the United States is but a tiny fraction of this number. If prevention was only to reduce this population of afflicted individuals by 20% or 7,650,000 cases a year, it would have exceeded the total treatment capacity for the United States for any given year. Given that not all clinical interventions are either successful or are directed at those defined as most seriously ill, the cost-benefit ratio of prevention becomes readily apparent. But even more important than the cost-benefit ratio favoring prevention would be the reality that millions of children and adults would have avoided unnecessary suffering. W h e r e D o e s P r i m a r y P r e v e n t i o n Occur?
Opportunities for prevention are everywhere. Prevention occurs at home when a parent using the skills learned in a parenting effectiveness class applies that knowledge to correcting a child's behavior without resorting to violent measures. Prevention happens in a group of disabled individuals when they form a self-help community in which members belong, are valued, and make meaningful cont, ibutions to the existence of the group. Prevention comes with the Americans with Disabilities Act, with civil rights legislation, and with family leave legislation. It rises with mandatory seat belt, helmet, and gun control laws. Prevention comes from an individual seriously heeding the caution statement on a cigarette package or alcohol bottle. Prevention happens when a child is enabled to anticipate a needed hospital visit. Prevention occurs when the child's parents are permitted to remain with the child during her or his hospital stay. Prevention transpires when coaches use learned skills (Danish, 1990) to promote the social competency of their student athletes or when schools and parents facilitate the entry of transfer students into new educational settings (Jason, Kurasaki, Neuson, and Garcia, 1993).
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9
Citizen opportunities for preventive interventions surround us. For health care professionals, however, prevention is when we planfully intervene with prevention's technology to effect group change in an as yet unaffected population. That is the where of prevention. When Does Prevention Happen?
Prevention happens before the onset of dysfunctional behavior and continues across the lifespan. Universal interventions like polio, measles, and other early childhood inoculations are illustrations of preventive actions taken before the onset of damaging childhood diseases. The use of seat belts and air bags to reduce the incidence of injury in motor vehicle accidents also serve as examples. Prenatal medical and nutritional care and educational classes are still other illustrations of preventive activity for ensuring healthy outcomes for child and mother. Using this understanding, it is not only acceptable but desirable to undertake preventive interventions with vulnerable or high risk groups. For example, I used the term universal intervention for early childhood inoculations. Yet, for poor, migrant, or homeless children, the probability of inoculation is not at all certain. In a health care system designed for the middle and upper classes, accessing care may be a significant challenge for others. Specifically targeting these children in a planful way for inoculations and other health care is prevention. There are still other populations that have been identified by epidemiological and clinical case studies to be at higher risk for additional specific dysfunctional behaviors. For example, while abstaining from premarital sexual relations is desirable, most youth do not. By age 19, more than 50% of females and more than 64% of males have engaged in intercourse. Further, adolescents are notorious for failing to use contraceptives. Fewer than half of sexually active adolescents regularly use contraceptives. Fewer still use contraceptives that decrease the probability of sexually transmitted diseases. This failure to practice safe sex exposes the adolescent to unintended pregnancy and a host of possible i l l n e s s e s - some deadly. Interventions with this at risk group are clearly desirable (Adams, Gullotta, and Markstrom-Adams, 1994). Finally, preventionists recognize that one shot interventions are very likely to be unsuccessful. Patterns of behavior develop over extended periods of time. To assume that a single intervention or even a series of interventions over several months will result in lifelong behavioral change is unrealistic. No other field holds this expectation.
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For example, an individual treated for cancer is considered cured if a period of five years passes without the return of the disease. If in the sixth year cancer is rediscovered then that is considered a new case. In certain treatment programs like intensive family preservation, the passage of one year, after the intervention without a referral of the identified family to protective service, is considered a successful intervention. This treatment intervention is not considered to have failed if the treated family is referred in the 13th month or thereafter. Finally, consider the flu shot. There is no expectation that if inoculated once that lifelong protection is extended against all forms of flu or even one form. The expectation is that to receive some protection the flu shot must be given yearly. Using the aforementioned standards, programs like Head Start and scores of others are resounding successes. Prevention should be held accountable. It should be expected to demonstrate its effectiveness. But it should not be held to a higher standard than exists for other fields.
How Does Primary Prevention Happen?
Acting as consultants and collaborators, health care professionals use primary prevention's technology of education, competency promotion, community organization~systems intervention, and natural caregiving to encourage the growth of functional behaviors in society. While professional disciplines have a vitally important role to preform in encouraging society's health, it always must be remembered that the burden of responsibility for health belongs to the individual. It is the preventionists role to construct opportunities for health, to remove barriers that impede health, and to alter circumstances that discourage health. Nevertheless, it is the individual who ultimately will decide whether or not to ignore those opportunities and choose a dysfunctional (unhealthy) lifestyle. Preventionists are junior partners in this alliance towards good health using their skills as consultants and collaborators to improve a community's health. Consultation involves the provision of technical assistance by health care professionals who share their skills, knowledge, and training with others to prevent dysfunctional behaviors while promoting functional behaviors. This contrasts with the more active "hands on" activity found in collaboration. Collaboration is an active partnership of professional enablers working directly with groups encouraging their involvement and ownership in issues that affect their health.The tools that preventionists use are education, competency promotion, community organization/systems intervention, and natural caregiving to encourage the growth of functional behaviors in society (Gullotta, 1987).
Principles of Primary Prevention
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Education is predicated on the belief that human beings are rational creatures capable of learning from their experiences and the experiences of others. In each of its three forms, it can be used to ease the passage from one life event to another or it can be given to individuals to enhance their well-being. Education can take the form of public information like that found in public service announcements, films, curricula, and this manuscript. It can take the form of anticipatory guidance, preparing individuals for retirement, marriage, childbirth, or the many other passage points that mark the flow of life. Education may take the form of behavioral approaches such as biofeedback or progressive relaxation in which individuals learn to gain greater control over their bodies. Education is prevention's most often used tool and also its weakest. Information and the attitudinal change it may create does not necessarily lead to behavioral change. Indeed, in my long association with The Journal of Primary Prevention, I cannot recall a single instance of reviewing a manuscript in which an educational intervention alone had the desired effect of changing a dysfunctional behavior. Increase knowledge, influence attitudes, but not change behavior. It is when education is combined with the next three tools that change is most often likely to occur. Indeed, I would suggest to my colleagues that it is only when an initiative contains a recognition of and use of all four tools that it should be considered a prevention approach. Prevention's second tool, competency promotion, is defined as activities that promote belonging to a group, being valued as a member by that group, and being able to make a meaningful contribution to the existence and continuation of that group. The psychological literature is rich in findings that high self-esteem, an internal locus of control, and community interested rather than self-invested citizens are strongly related to functional societal behaviors. Activities that promote social competency promote resiliency. That is the ability for an individual to withstand adverse social, emotional, and health circumstances and succeed where others typically have failed. This tool may take passive (intellectual) approaches such as assertiveness training, affective education, or religious instruction. It also may take more active (physical) approaches like that found in "Outward Bound" or "Rope" (Blumenkrantz and Gavazzi, 1993). Competency promotion like many of the tools being discussed in this manuscript share similar characteristics. The distinction between education and competency promotion involves outcome. In the first case, the outcome is increased knowledge leading to attitudinal and behavioral change. In the second instance, the outcome is connectedness leading to an investment in society.
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Prevention's next tool is community organization/systems intervention (CO/SI). The ability to live life effectively is sometimes impeded by forces beyond one's personal abilities. Such forces interfere with or limit access to life options and opportunities. This tool is used to redress these inequities. Obstructions can be removed in any of three ways. The first is the modification or removal of institutional practice barriers. For instance, the relatively new practice of permitting fathers in the delivery room is one example of removing an institutional practice barrier to facilitating infant-father attachment and bonding at birth. A second example would be the practice of providing parents with overnight accommodations to remain with their hospitalized children. The second form CO/SI may take is community resource development. One example of community resource development would be the modification of buildings to permit access by all. The development of neighborhood associations to improve community living conditions is yet another example. The third CO/SI approach is legislative or judicial action leading to empowerment. Efforts by the National Association for the Advancement of Colored People in the area of civil rights, Mothers Against Drunk Driving in the area of stricter enforcement of laws regarding drunk driving, and Disabled American Rights groups efforts on behalf of ADA legislation illustrate the effectiveness this tool can have in changing behavior. Community organization/systems intervention is the most powerful of all of prevention's tools. And yet it is the tool least discussed by mental health professionals. In contrast to education which uses knowledge to effect attitudinal and then behavioral change, CO/SI uses the judiciary, legislative, and community action to effect change giving little attention or care about attitudes. Community action whether in the form of changing institution practices (urging the discontinuation of ability tracking of school students, for example), promoting neighborhood change (in enforcing building code regulations), or encouraging legislative action (in the form of tougher gun control laws) is territory social scientists in recent years have avoided. Effective primary prevention programs enable affected individuals to confront these issues and work towards changing these dysfunctional societal conditions. Prevention's fourth tool is natural caregiving. Caring for oneself, for another, for each other I t h a t is the essence of natural caregiving. The vast majority of citizens struggle through life never seeking paid advice, guidance, or support. Rather, that assistance is found and drawn from the supportive environment surrounding the individual. That spring of emotional strength can flow from several sources. When social support takes the form of help from teachers or the clergy, it is called trained indigenous caregiving. This phrase is an acknowledgement that society has placed helping expectations of a physical and emotional nature on some professions
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that historically have had no formal educational connection to the mental health disciplines. While teachers, the clergy, and the police continue in roles not commonly associated with mental health, increasingly attention has been given to enriching the skills and enabling the ability of these professions to promote the public's health. Mutual self-help groups are a second form of caregiving. It occurs when an individual is both a caregiver and care receiver in a group not led by a mental health professional. As all the previous forms of caregiving involved behaviors such as the sharing of knowledge, the sharing of experiences, compassionate understanding, companionship, and, when necessary, confrontation (Bloom, in progress; Cowen, 1982), this final form of caregiving is individual in nature. The indigenous caregiver accepts responsibility for her or his life and, as I have long asked my students over the years, invests in the life (health) of at least one other individual.
CONCLUSION This brief review of primary prevention hopefully will lead the reader to other works on this subject. Of the many excellent books on the topic, I would refer the reader to the following overviews: Principles of Preventive Psychiatry (Caplan, 1964), Primary Prevention of Psychopathology Volume I: The Issues (Albee and Joffe, 1977), Primary Prevention: The Possible Science (Bloom, 1981), Concepts of Primary Prevention: A Framework for Program Development (Goldston, 1987), 14 Ounces of Prevention (Price, Cowen, Lorion, and Ramos-McKay, 1988) and Primary Prevention Practices (Bloom, in progress). Two Sage Publication book series, one sponsored by the Vermont Conference on the Primary Prevention of Psychopathology entitled Primary Prevention of Psychopathology and the other by Child and Family Agency entitled Issues in Children's and Families' Lives, are recommended for their comprehensive coverage of prevention issues applied to specific subject issues like family violence (Hampton, Gullotta, Adams, Potter, and Weissberg, 1993). Hopefully, this review of prevention's principles will speed the entry of new disciplines into this promising area of health promotion. Ideally. it will also serve as a reminder that prevention does not belong to any one discipline. No one professional organization, federal or state department has an exclusive claim to its title. Finally, beware the "magic bullet" for there is no specific initiative, as this paper has shared, that is exclusive to preventing a single dysfunctional behavior. Prevention is comprehensive; it extends over time; it belongs to the people; and its technology is generic.
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REFERENCES Adams, G. R., Gullotta, T. P., and Markstrom-Adams, C. (1994). Adolescent life experiences. Pacific Grove, CA: Brooks/Cole. Albee, G. W. (1983). Psychopathology, prevention, and the just society. Journal of Primary Prevention, 4(1), 5-40. Albee, G. W. (1985). The argument for primary prevention. Journal of Primary Prevention, 5(4), 213-219. Albee, G. W. (1987). The rationale and need for primary prevention. In S. E. Goldston (Ed.) Concepts of primary prevention: A framework for program development. Los Angeles, CA: California Department of Mental Health. Albee, G. W., and Gullotta, T. P. (1986). Facts and fallacies about primary prevention. Journal of Primary Prevention, 6(4) 207-218. Albee, G. W., and Joffe, J. M. (1977). Primary prevention of psychopathology Volume 1: The issues. Hanover, New Hampshire: University Press of New England. Bloom, M. (1981). Primary prevention: The possible science. Englewood Cliffs, N.J.: Prentice-Hail. Bloom, M. (in progress). Primary prevention practices. Author. Blumenkrantz, D. G., and Gavazzi, S. M. (1993). Guiding transitional events for children and adolescents through a modern day rite of passage. Journal of Primary Prevention, 13(3) 199-212. Caplan, G. (1964). Principles of preventive psychiatry. NY: Basic Books. Committee on Preventive Psychiatry. (1980). Mental health andprimary medical care. NY, NY: Group for the Advancement of Psychiatry. Cowen, E. L. (1982). Help is where you find it: Four informal helping groups. American Psychologist, 37, 385-395. Danish, S. J., Petitpas, A. J., and Hale, B. D. (1990). Sport as a context for developing competence. In T. P. GuUotta, G. R. Adams, and R. Montemayor (Eds.), Developing social competence in adolescence. Newbury Park, CA: Sage. Goldston, S. E. (Ed.). (1987). Concepts of primary prevention: A framework for program development. Los Angeles, CA: California Department of Mental Health. Gullotta, T. P. (1987). Prevention's technology. Journal of Primary Prevention, 8,(1&2), 4-24. Hampton, R. L., Gullotta, T. P., Adams, G. R., Potter, E. H., and Weissberg, R. P. (1993). Issues in children's and families' lives Volume 1: Family violence. Newbury Park, CA: Sage. Holden, C. (1987). Is alcoholism treatment effective? Science, 236, 20-22. Holden, C. (1991). Depression: The news isn't depressing. Science, 254, 1450-1452. Jason, L. A., Kurasaki, K. S., Neuson, L., and Garcia, C. (1993). Training parents in a preventive intervention for transfer children. Journal of Primary Prevention, 13(3), 213-227. Klein, D. C., and Goldston, S. E. (Eds.). (1977). Primmy prevention: An idea whose time has come. Washington, DC: National Institute of Mental Health. National Commission on Children (1991). Beyond rhetoric:A new American agenda for children and families. Washington, DC: U. S. Government Printing Office. Peele, S. (1986). The implications and limitations of genetic models of alcoholism and other addictions. Journal of Studies on Alcohol, 47(1), 63-73. Plomin, R. (1990). The role of inheritance in behavior. Sc&nce, 248, 183-188. Price, R., Cowen, E., Lotion, R., and Ramos-McKay, J. (Eds.) (1988). 14 ounces of prevention: A casebook for practitioners. Washington, DC: American Psychological Association.
The What, Who, Why, Where, When, and How of Primary Prevention T h o m a s P. G u l l o t t a I
This paper discusses primary prevention's basic tenets and generic principles. It describes its essential elements and explains how prevention's technology of education, social competency, community organization~systems intervention, and natural caregiving can be used to prevent dysfunctional behaviors while promoting healthy lifestyles. KEY W O R D S : Primary prevention; prevention's technology; understanding primary
prevention.
In the Spring of 1993, I had the opportunity to participate on an advisory panel for the Center for Substance Abuse Prevention. Drawn from several professional organizations, panel members spent three difficult days attempting to advise a group of contractors on the development of prevention curriculums for disciplines like social work, nursing, dentistry, community health center staff, and rehabilitation specialists. I use the word difficult intentionally because few of the panel members could agree on even a common definition for primary prevention. Rather, hindered by the limitations of our educational paradigms and world experiences, each of us defined prevention to generally encompass current work activities. I had a similar but briefer experience several months later at a National Institute of Health conference. Billed as, "Disease Prevention Research At NIH: An Agenda For All," I had the sensation that NIH's much trumpeted decade of the brain was being repackaged into the more currently and politically correct language of prevention. These recent experiences serve as the motivation for undertaking this article. It is an lDirect all inquiries to Thomas P. Gullotta, Child and Family Agency, 255 Hempstead Street, New London, CT. 06320.
9 1994Human SciencesPress, Inc.
6
Gullota
attempt to describe primary prevention in a way not belonging to any one discipline or field. It is an attempt to discuss primary prevention in a manner that illustrates its basic tenets and principles. What is Primary Prevention?
Primary prevention can be defined as planned efforts to reduce (prevenO the incidence of new cases of dysfunctional behavior in a population not yet demonstrafing signs of dysfunctional behavior and to encourage (promote) behaviors that are known to contribute to functional behaviors. This definition avoids using words like illness and health, although in latter paragraphs I will use these and other words interchangeably with functional and dysfunctional behavior. Words like illness or health frequently can be construed to imply a biological origin for behavior. While I will not deny that some dysfunctional behaviors may contain a biological component, most do not. And even those behaviors that have attracted the greatest biological interest (alcoholism and depression) still remain elusive targets for the geneticists who even in the best of their imperfect studies must continue to attribute one-half or more of the variance to environmental variables (see Holden, 1987, 1991; Peele, 1986; Plomin, 1990). Rather dysfunctional behaviors are most often the result of flawed interpersonal or person to society relationships (Albee, 1983, 1987). Who is the Focus of Primary Prevention Activities?
Primary prevention focuses on healthy populations. The why of the who can be found in the what of primary prevention. That is, primary prevention is concerned with reducing the incidence of new cases of dysfunctional behavior in a society while encouraging lifestyles that encourage functional behaviors in society. Treatment is not prevention. Rehabilitation is not prevention. Does this mean that recently brain injuries individuals may not benefit from primary prevention initiatives? Certainly not. If the initiative is to promote understanding and the acceptance of individuals with disabilities in the wider society, then this is a most appropriate population with whom to be involved. If the initiative is a group focused set of activities (involving education, competency promotion, self-help, and community change) to prevent the clinical depression that frequently follows serious injuries of this nature, then this is, again, a most appropriate population with whom to be involved. Incidentally, in the first example note that it is the general public that is the target for changed behavior.
Principles of Primary Prevention
7
A n o t h e r w h o p o i n t is f o u n d in the w o r d "society". F o r m e n t a l health, public health, and o t h e r professional helping disciplines, prev e n t i o n is group not individually focused (Klein and G o l d s t o n , 1977). T h e s e proactive p o p u l a t i o n efforts u n d e r t a k e n by professional helping disciplines are i n t e n d e d to e n c o u r a g e o t h e r s to act on an individual basis to p r o m o t e functional behaviors. By equipping teachers, clergy, y o u t h leaders, b a r t e n d e r s , hairdressers, media r e p o r t e r s , students, parents, friends, and others with the ability, skills, and knowledge to prom o t e f u n c t i o n a l b e h a v i o r s in t h e m s e l v e s a n d o t h e r s , p r e v e n t i o n happens. F r o m the symbolic interactionist perspective, it is w h e n mental health professionals exchange their roles as clinicians for o t h e r roles like parent, spouse, friend, or y o u t h leader, that they have the o p p o r tunity (acting as private citizens) to p r o m o t e functional behaviors for themselves and others. Incidentally, to revisit the earlier example of the recently brain injured individual, all of the aforementioned prevention educated groups would have encouraged the behavior that wearing a helmet while riding a bike, horse, motorcycle, or skate board was a wise and sensible act to practice. T o avoid a disabling brain injury is preferable to either preventing the subsequent depression that frequently follows such an injury or promoting the societal acceptance of individuals who have experienced such an unfortunate occurrence.
Why is P r i m a r y Prevention Necessary?
Primary prevention makes sense. That is dollar "cents" and wellness sense. F r o m the old adage that an ounce of prevention is worth a pound of cure to the reality that American citizens can no longer support the cost of a seemingly ever expanding health care industry mesmerized with high technology, prevention makes sense. As noted earlier, most of the dysfunctional behaviors (illnesses) affecting individuals are lifestyle decisions. These are decisions that can and should be influenced toward more functional (healthier) behaviors. As the National Commission on Children (1991, p. 126-127) noted in their report Beyond Rhetoric: A New American
Agenda for Children and Families: Malnourishment, obesity, and the incidence of many illnesses are related to nutritional intake. Sexuallytransmitted diseases, accidents and injuries, and physical and mental impairments are directly attributable to early, unprotected sexual activity, drug and alcohol use, and delinquent behavior . . . . In fact, better control of a limited number of risk factors . . . could prevent at least 40 percent of all premature deaths, one-third of all short-term disability cases, and two-thirds of all
8
Gullota
chronic disabilitycases. Changes in health behaviors can also reduce medical costs and limit losses in productivity. Illnesses attributable to smoking cost individuals and society more than $65 billion a year. The total cost of alcohol and drug abuse exceeds $110 billion each year. (National Commissionon Children, 1991: p. 126-127) Investing in prevention will not mean the demise of either mental health treatment or rehabilitation services. Indeed, as George Albee (1983, 1985, and Gullotta, 1986) and others (Committee on Preventive Psychiatry, 1980) have pointed out, epidemiological studies suggest that in any given year 15% of the population of the United States are (to use the language of the health care industry) seriously emotionally ill. With an estimated U n i t e d States population of 255,000,000 individuals, this means that roughly 38,250,000 individuals are yearly in need of help. Yet, the treatment and rehabilitation capacity of the United States is but a tiny fraction of this number. If prevention was only to reduce this population of afflicted individuals by 20% or 7,650,000 cases a year, it would have exceeded the total treatment capacity for the United States for any given year. Given that not all clinical interventions are either successful or are directed at those defined as most seriously ill, the cost-benefit ratio of prevention becomes readily apparent. But even more important than the cost-benefit ratio favoring prevention would be the reality that millions of children and adults would have avoided unnecessary suffering. W h e r e D o e s P r i m a r y P r e v e n t i o n Occur?
Opportunities for prevention are everywhere. Prevention occurs at home when a parent using the skills learned in a parenting effectiveness class applies that knowledge to correcting a child's behavior without resorting to violent measures. Prevention happens in a group of disabled individuals when they form a self-help community in which members belong, are valued, and make meaningful cont, ibutions to the existence of the group. Prevention comes with the Americans with Disabilities Act, with civil rights legislation, and with family leave legislation. It rises with mandatory seat belt, helmet, and gun control laws. Prevention comes from an individual seriously heeding the caution statement on a cigarette package or alcohol bottle. Prevention happens when a child is enabled to anticipate a needed hospital visit. Prevention occurs when the child's parents are permitted to remain with the child during her or his hospital stay. Prevention transpires when coaches use learned skills (Danish, 1990) to promote the social competency of their student athletes or when schools and parents facilitate the entry of transfer students into new educational settings (Jason, Kurasaki, Neuson, and Garcia, 1993).
Principles of Primary Prevention
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Citizen opportunities for preventive interventions surround us. For health care professionals, however, prevention is when we planfully intervene with prevention's technology to effect group change in an as yet unaffected population. That is the where of prevention. When Does Prevention Happen?
Prevention happens before the onset of dysfunctional behavior and continues across the lifespan. Universal interventions like polio, measles, and other early childhood inoculations are illustrations of preventive actions taken before the onset of damaging childhood diseases. The use of seat belts and air bags to reduce the incidence of injury in motor vehicle accidents also serve as examples. Prenatal medical and nutritional care and educational classes are still other illustrations of preventive activity for ensuring healthy outcomes for child and mother. Using this understanding, it is not only acceptable but desirable to undertake preventive interventions with vulnerable or high risk groups. For example, I used the term universal intervention for early childhood inoculations. Yet, for poor, migrant, or homeless children, the probability of inoculation is not at all certain. In a health care system designed for the middle and upper classes, accessing care may be a significant challenge for others. Specifically targeting these children in a planful way for inoculations and other health care is prevention. There are still other populations that have been identified by epidemiological and clinical case studies to be at higher risk for additional specific dysfunctional behaviors. For example, while abstaining from premarital sexual relations is desirable, most youth do not. By age 19, more than 50% of females and more than 64% of males have engaged in intercourse. Further, adolescents are notorious for failing to use contraceptives. Fewer than half of sexually active adolescents regularly use contraceptives. Fewer still use contraceptives that decrease the probability of sexually transmitted diseases. This failure to practice safe sex exposes the adolescent to unintended pregnancy and a host of possible i l l n e s s e s - some deadly. Interventions with this at risk group are clearly desirable (Adams, Gullotta, and Markstrom-Adams, 1994). Finally, preventionists recognize that one shot interventions are very likely to be unsuccessful. Patterns of behavior develop over extended periods of time. To assume that a single intervention or even a series of interventions over several months will result in lifelong behavioral change is unrealistic. No other field holds this expectation.
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For example, an individual treated for cancer is considered cured if a period of five years passes without the return of the disease. If in the sixth year cancer is rediscovered then that is considered a new case. In certain treatment programs like intensive family preservation, the passage of one year, after the intervention without a referral of the identified family to protective service, is considered a successful intervention. This treatment intervention is not considered to have failed if the treated family is referred in the 13th month or thereafter. Finally, consider the flu shot. There is no expectation that if inoculated once that lifelong protection is extended against all forms of flu or even one form. The expectation is that to receive some protection the flu shot must be given yearly. Using the aforementioned standards, programs like Head Start and scores of others are resounding successes. Prevention should be held accountable. It should be expected to demonstrate its effectiveness. But it should not be held to a higher standard than exists for other fields.
How Does Primary Prevention Happen?
Acting as consultants and collaborators, health care professionals use primary prevention's technology of education, competency promotion, community organization~systems intervention, and natural caregiving to encourage the growth of functional behaviors in society. While professional disciplines have a vitally important role to preform in encouraging society's health, it always must be remembered that the burden of responsibility for health belongs to the individual. It is the preventionists role to construct opportunities for health, to remove barriers that impede health, and to alter circumstances that discourage health. Nevertheless, it is the individual who ultimately will decide whether or not to ignore those opportunities and choose a dysfunctional (unhealthy) lifestyle. Preventionists are junior partners in this alliance towards good health using their skills as consultants and collaborators to improve a community's health. Consultation involves the provision of technical assistance by health care professionals who share their skills, knowledge, and training with others to prevent dysfunctional behaviors while promoting functional behaviors. This contrasts with the more active "hands on" activity found in collaboration. Collaboration is an active partnership of professional enablers working directly with groups encouraging their involvement and ownership in issues that affect their health.The tools that preventionists use are education, competency promotion, community organization/systems intervention, and natural caregiving to encourage the growth of functional behaviors in society (Gullotta, 1987).
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Education is predicated on the belief that human beings are rational creatures capable of learning from their experiences and the experiences of others. In each of its three forms, it can be used to ease the passage from one life event to another or it can be given to individuals to enhance their well-being. Education can take the form of public information like that found in public service announcements, films, curricula, and this manuscript. It can take the form of anticipatory guidance, preparing individuals for retirement, marriage, childbirth, or the many other passage points that mark the flow of life. Education may take the form of behavioral approaches such as biofeedback or progressive relaxation in which individuals learn to gain greater control over their bodies. Education is prevention's most often used tool and also its weakest. Information and the attitudinal change it may create does not necessarily lead to behavioral change. Indeed, in my long association with The Journal of Primary Prevention, I cannot recall a single instance of reviewing a manuscript in which an educational intervention alone had the desired effect of changing a dysfunctional behavior. Increase knowledge, influence attitudes, but not change behavior. It is when education is combined with the next three tools that change is most often likely to occur. Indeed, I would suggest to my colleagues that it is only when an initiative contains a recognition of and use of all four tools that it should be considered a prevention approach. Prevention's second tool, competency promotion, is defined as activities that promote belonging to a group, being valued as a member by that group, and being able to make a meaningful contribution to the existence and continuation of that group. The psychological literature is rich in findings that high self-esteem, an internal locus of control, and community interested rather than self-invested citizens are strongly related to functional societal behaviors. Activities that promote social competency promote resiliency. That is the ability for an individual to withstand adverse social, emotional, and health circumstances and succeed where others typically have failed. This tool may take passive (intellectual) approaches such as assertiveness training, affective education, or religious instruction. It also may take more active (physical) approaches like that found in "Outward Bound" or "Rope" (Blumenkrantz and Gavazzi, 1993). Competency promotion like many of the tools being discussed in this manuscript share similar characteristics. The distinction between education and competency promotion involves outcome. In the first case, the outcome is increased knowledge leading to attitudinal and behavioral change. In the second instance, the outcome is connectedness leading to an investment in society.
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Prevention's next tool is community organization/systems intervention (CO/SI). The ability to live life effectively is sometimes impeded by forces beyond one's personal abilities. Such forces interfere with or limit access to life options and opportunities. This tool is used to redress these inequities. Obstructions can be removed in any of three ways. The first is the modification or removal of institutional practice barriers. For instance, the relatively new practice of permitting fathers in the delivery room is one example of removing an institutional practice barrier to facilitating infant-father attachment and bonding at birth. A second example would be the practice of providing parents with overnight accommodations to remain with their hospitalized children. The second form CO/SI may take is community resource development. One example of community resource development would be the modification of buildings to permit access by all. The development of neighborhood associations to improve community living conditions is yet another example. The third CO/SI approach is legislative or judicial action leading to empowerment. Efforts by the National Association for the Advancement of Colored People in the area of civil rights, Mothers Against Drunk Driving in the area of stricter enforcement of laws regarding drunk driving, and Disabled American Rights groups efforts on behalf of ADA legislation illustrate the effectiveness this tool can have in changing behavior. Community organization/systems intervention is the most powerful of all of prevention's tools. And yet it is the tool least discussed by mental health professionals. In contrast to education which uses knowledge to effect attitudinal and then behavioral change, CO/SI uses the judiciary, legislative, and community action to effect change giving little attention or care about attitudes. Community action whether in the form of changing institution practices (urging the discontinuation of ability tracking of school students, for example), promoting neighborhood change (in enforcing building code regulations), or encouraging legislative action (in the form of tougher gun control laws) is territory social scientists in recent years have avoided. Effective primary prevention programs enable affected individuals to confront these issues and work towards changing these dysfunctional societal conditions. Prevention's fourth tool is natural caregiving. Caring for oneself, for another, for each other I t h a t is the essence of natural caregiving. The vast majority of citizens struggle through life never seeking paid advice, guidance, or support. Rather, that assistance is found and drawn from the supportive environment surrounding the individual. That spring of emotional strength can flow from several sources. When social support takes the form of help from teachers or the clergy, it is called trained indigenous caregiving. This phrase is an acknowledgement that society has placed helping expectations of a physical and emotional nature on some professions
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that historically have had no formal educational connection to the mental health disciplines. While teachers, the clergy, and the police continue in roles not commonly associated with mental health, increasingly attention has been given to enriching the skills and enabling the ability of these professions to promote the public's health. Mutual self-help groups are a second form of caregiving. It occurs when an individual is both a caregiver and care receiver in a group not led by a mental health professional. As all the previous forms of caregiving involved behaviors such as the sharing of knowledge, the sharing of experiences, compassionate understanding, companionship, and, when necessary, confrontation (Bloom, in progress; Cowen, 1982), this final form of caregiving is individual in nature. The indigenous caregiver accepts responsibility for her or his life and, as I have long asked my students over the years, invests in the life (health) of at least one other individual.
CONCLUSION This brief review of primary prevention hopefully will lead the reader to other works on this subject. Of the many excellent books on the topic, I would refer the reader to the following overviews: Principles of Preventive Psychiatry (Caplan, 1964), Primary Prevention of Psychopathology Volume I: The Issues (Albee and Joffe, 1977), Primary Prevention: The Possible Science (Bloom, 1981), Concepts of Primary Prevention: A Framework for Program Development (Goldston, 1987), 14 Ounces of Prevention (Price, Cowen, Lorion, and Ramos-McKay, 1988) and Primary Prevention Practices (Bloom, in progress). Two Sage Publication book series, one sponsored by the Vermont Conference on the Primary Prevention of Psychopathology entitled Primary Prevention of Psychopathology and the other by Child and Family Agency entitled Issues in Children's and Families' Lives, are recommended for their comprehensive coverage of prevention issues applied to specific subject issues like family violence (Hampton, Gullotta, Adams, Potter, and Weissberg, 1993). Hopefully, this review of prevention's principles will speed the entry of new disciplines into this promising area of health promotion. Ideally. it will also serve as a reminder that prevention does not belong to any one discipline. No one professional organization, federal or state department has an exclusive claim to its title. Finally, beware the "magic bullet" for there is no specific initiative, as this paper has shared, that is exclusive to preventing a single dysfunctional behavior. Prevention is comprehensive; it extends over time; it belongs to the people; and its technology is generic.
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REFERENCES Adams, G. R., Gullotta, T. P., and Markstrom-Adams, C. (1994). Adolescent life experiences. Pacific Grove, CA: Brooks/Cole. Albee, G. W. (1983). Psychopathology, prevention, and the just society. Journal of Primary Prevention, 4(1), 5-40. Albee, G. W. (1985). The argument for primary prevention. Journal of Primary Prevention, 5(4), 213-219. Albee, G. W. (1987). The rationale and need for primary prevention. In S. E. Goldston (Ed.) Concepts of primary prevention: A framework for program development. Los Angeles, CA: California Department of Mental Health. Albee, G. W., and Gullotta, T. P. (1986). Facts and fallacies about primary prevention. Journal of Primary Prevention, 6(4) 207-218. Albee, G. W., and Joffe, J. M. (1977). Primary prevention of psychopathology Volume 1: The issues. Hanover, New Hampshire: University Press of New England. Bloom, M. (1981). Primary prevention: The possible science. Englewood Cliffs, N.J.: Prentice-Hail. Bloom, M. (in progress). Primary prevention practices. Author. Blumenkrantz, D. G., and Gavazzi, S. M. (1993). Guiding transitional events for children and adolescents through a modern day rite of passage. Journal of Primary Prevention, 13(3) 199-212. Caplan, G. (1964). Principles of preventive psychiatry. NY: Basic Books. Committee on Preventive Psychiatry. (1980). Mental health andprimary medical care. NY, NY: Group for the Advancement of Psychiatry. Cowen, E. L. (1982). Help is where you find it: Four informal helping groups. American Psychologist, 37, 385-395. Danish, S. J., Petitpas, A. J., and Hale, B. D. (1990). Sport as a context for developing competence. In T. P. GuUotta, G. R. Adams, and R. Montemayor (Eds.), Developing social competence in adolescence. Newbury Park, CA: Sage. Goldston, S. E. (Ed.). (1987). Concepts of primary prevention: A framework for program development. Los Angeles, CA: California Department of Mental Health. Gullotta, T. P. (1987). Prevention's technology. Journal of Primary Prevention, 8,(1&2), 4-24. Hampton, R. L., Gullotta, T. P., Adams, G. R., Potter, E. H., and Weissberg, R. P. (1993). Issues in children's and families' lives Volume 1: Family violence. Newbury Park, CA: Sage. Holden, C. (1987). Is alcoholism treatment effective? Science, 236, 20-22. Holden, C. (1991). Depression: The news isn't depressing. Science, 254, 1450-1452. Jason, L. A., Kurasaki, K. S., Neuson, L., and Garcia, C. (1993). Training parents in a preventive intervention for transfer children. Journal of Primary Prevention, 13(3), 213-227. Klein, D. C., and Goldston, S. E. (Eds.). (1977). Primmy prevention: An idea whose time has come. Washington, DC: National Institute of Mental Health. National Commission on Children (1991). Beyond rhetoric:A new American agenda for children and families. Washington, DC: U. S. Government Printing Office. Peele, S. (1986). The implications and limitations of genetic models of alcoholism and other addictions. Journal of Studies on Alcohol, 47(1), 63-73. Plomin, R. (1990). The role of inheritance in behavior. Sc&nce, 248, 183-188. Price, R., Cowen, E., Lotion, R., and Ramos-McKay, J. (Eds.) (1988). 14 ounces of prevention: A casebook for practitioners. Washington, DC: American Psychological Association.
