Prevention Programs

Prevention Programs

Urban Institute Project Report

Problem Behavior Prevention and School-Based Health Centers:
Programs and Prospects

CHAPTER FOUR

Assessing School-Based Health Centers for a Problem Behavior Prevention Role

Introduction

In Chapter 2, we addressed the first major study question: Are there prevention programs conducted in school or non-school settings that have positive impact on the main risk behaviors facing children and adolescents? We presented descriptions of more than 50 programs that appeared to be effective and met reasonably rigorous research design and evaluation selection criteria. In Chapter 3, we highlighted the salient approaches, components, and elements common to successful interventions across problem behaviors that were derived from a synthesis of well evaluated, seminal interventions. In this chapter, we begin to answer the second major study question: What would it take for SBHCs, alone or in partnership with their host school(s) and immediate communities, to become effective settings for delivering prevention interventions such as those identified in Chapter 2? That is, what steps would need to be taken and what changes would need to be made for SBHCs to play a significant long-term role in the prevention of problem behaviors among risk-taking youth?

In answering these questions, we use the knowledge gained from each of the study tasks/activities. This includes information derived from reviewing and "deconstructing" the salient elements of successful programs; the experiences and insights of the advisory panel whose members had experience working with or directly observing SBHC activities; the leading prevention experts (all of whom have made significant programming or evaluation contributions to the prevention intervention literature, but had not involved SBHCs in their research previously); the MTG senior staff who have great knowledge of how SBHCs operate in the real world; and the prevention program coordinators and other staff from two SBHCs visited by UI project staff.

Our study approaches, methods, and tasks evolved and changed over the study period. Originally, a number of site visits by the advisory panel and UI project staff to prevention programs with strong empirical support or with great promise based on their preliminary findings were planned. As successful programs were identified through professional journals and book chapters, some with lengthy publication lag times, it was clear that the intervention phase had already been completed for almost all projects of interest, the follow-up data collection phase(s) had been completed for many, and none of the programs was continuing to operate in its original setting. Moreover, we could not readily locate sites where even the most successful programs were being fully implemented in a new setting. These circumstances precluded the possibility of visiting empirically-validated programs.

Then, following discussions with the project advisory panel, the original RWJ Foundation project officer (Rush Russell), and MTG senior staff, we developed an alternative approach. We identified a group of experts on problem behavior prevention research and evaluation whose own programs had been well evaluated and whose work had moved the field forward (and informed our initial program search and literature review). They were invited to make site visits to SBHCs in their areas with the objectives of assessing the potential for incorporating approaches and programs similar to their own in such settings, as well as SBHCs’ overall problem behavior prevention prospects.

Ten prevention scientists with expertise in sexual behavior, substance use, violence prevention/conflict resolution, or mental health agreed to join the project. They discussed their impressions and shared their insights with UI project staff at one of two regional meetings also attended by MTG senior staff, available advisory panel members, and RWJF representatives.

To prepare for those discussions, the prevention experts were asked to consider ways in which their own program(s) might or might not be applicable to SBHC settings similar to the one(s) they visited, as well as what intervention components, elements, and staff characteristics might increase the chances for success of programs such as theirs, if they were to be conducted in SBHC settings?

Although the prevention experts responded to a common set of questions, they visited different and probably distinctive SBHCs. Moreover, for most it was their first exposure to a SBHC. In retrospect, their views about overall SBHC prevention promise and pitfalls appeared to be keyed to the characteristics of the particular site(s) they visited. In fact, these experts reported great variability in SBHC characteristics, including sponsorship, funding bases, school support, clinic settings and space, leadership, staffing patterns, available resources, and current prevention activities.

Foreshortening the breadth, depth, and richness of the discussions generated by the prevention scientists’ site visits and subsequent discussions with the advisory panel members and MTG staff, no simple answer became apparent to the basic question of whether SBHCs could successfully deliver the sorts of prevention programs identified in our review. However, preliminary answers to what we believe are salient elements of "prevention readiness" in SBHCs did emerge.

Briefly summarizing all of these discussions, it was concluded that schools will be at different stages of readiness to do prevention programs. Some may not have the motivation or resources to implement prevention programs and will need the expertise and materials to understand the need, while other SBHCs might have ideas for programs but lack the staffing or resources to implement them, and others may be providing some prevention activities already and wish to expand their coverage, but need information and advise on what form these programs could take. In addition to SBHCs varying in their programmatic needs, there will also be a range of activities that centers can implement, from single component programs such as counseling or health education that require little if no additional staff or resources to more multi-component programs that involve parents and extended communities that require more resources and staffing. In deciding the range and activity level that can be managed, SBHCs must consider their stage of readiness to initiate and sustain behaviorally-based prevention programming.

The following section, in the form of a "Prevention Readiness Checklist" is intended to distill the discussions and reflect many of the main contextual and ecological issues that SBHC’s face, as well as some prevention principles and factors that might enhance or limit program effects.

The Prevention Readiness Checklist outlines many of the necessary factors and conditions that affect SBHCs. The Checklist is not meant to encompass every condition that must be met, nor would it be necessary for a SBHC to satisfy every precondition in order to do a prevention program or programs successfully. Based on our discussions and experiences, we believe that the Checklist that follows includes most of the major questions and issues that a SBHC needs to consider before embarking on a prevention programming pathway.

PREVENTION READINESS CHECKLIST

SBHC Developmental Stage and Self-Assessment

How long has the SBHC been open?

How does the SBHC view its mission or role within its host school and community?

  • Provision of clinical/health services primarily?
  • Provision of clinical /health services + health-related education broadly defined?
  • First entry into the health care system for many students/families?
  • Some combination of the above?
  • Other role(s)?

What is the current status of the provision of clinical/health services?

  • Increasing/Stable/Decreasing?

    What is the current status of funding for the provision of clinical/health services?

  • Increasing/Stable/Decreasing?

    What is the current status of staffing for the provision of clinical/health services?

  • Increasing/Stable/Decreasing?

    What is the current status of the provision of health-related education?

  • Increasing/Stable/Decreasing?

    What is the current status of funding for the provision of health-related education?

  • Increasing/Stable/Decreasing?

    What is the current status of staffing for the provision of health-related education?

  • Increasing/Stable/Decreasing?

    Is the SBHC perceived positively by the host school?
  • If not, are there good prospects?

    Is the SBHC perceived positively by the immediate community?
  • If not, are there good prospects?

    Needs or Risk Assessment and Program Development

    Has a needs assessment been conducted to determine whether students are at (high) risk and the kind(s) of prevention program(s) that are needed?

  • If yes:
  • What are the prevalences of risk behaviors at the school?
  • What are the parental concerns about student behavior and about prevention topics?
  • What are the school and school district requirements regarding health promotion programming?
  • Are there major unmet health needs in the community? If yes, what are they?
  • Are there resources available in the school and in the community to assist in prevention programming? If yes, what are they? If not, are there good prospects for their development?

  • If no, is there a planning committee formed to get those data?

    Organizational Support

    Do sponsors of the SBHC support expansion of the existing program to include prevention activities?

    Does the staff of SBHC support expansion existing program to include prevention activities?

    Does the SBHC have to gain approval from the school, the school system administration, or the school board before starting new prevention activities?

  • If yes, can approval be gained?

    Does the SBHC have a positive working relationship with the school and the school system?

    Funding

    Does the SBHC have stable core funding for clinical/health services activities?

    Does the SBHC have adequate funding to get prevention initiatives started?

  • If not, are there good prospects?

    Has SBHC planning begun to establish or is there in place a realistic budget that considers what will be needed to expand into prevention programs, including staffing needs, materials, training, outreach, and marketing?

    Has SBHC planning begun or is there in place a plan for ensuring the sustainability and institutionalization of successful programs that may not have long-term funding?

    School Environment

    Is there pressure from the school district to improve student achievement that would interfere with introducing SBHC-based prevention efforts during students’ class time?

    Does the SBHC have a positive relationship with the administrative staff and faculty?

    Is the administrative staff supportive of the SBHC implementing prevention programs either alone or in conjunction with the school?

  • If no, are there good prospects?

    Is the majority of teachers supportive of the SBHC implementing prevention programs either alone or in conjunction with the school?

  • If no, are there good prospects?

    Is there adequate student free time and flexibility to allow prevention programs to be conducted in or in conjunction with the SBHC during school hours?

    Is the physical environment of the school conducive to academic and health promotion activities?

  • Are the school buildings safe?
  • Are the school buildings in adequate repair?

    Is the school’s classroom climate conducive to delivering prevention programming ? (Consider student-teacher relationships, class sizes, flexibility in teaching curricula at the school)?

    Are there adequate space provisions for the SBHC to expand to prevention programming?

  • If not, are there good prospects for expansion? Within the SBHC? Within the school? What additional space provisions would be necessary?

    SBHC Staffing

    Does the SBHC have sufficient staff to conduct new prevention programs and activities?

  • If yes, will the current staff need additional prevention-related training?
  • If no, would hiring additional staff with different professional training/skills create conflict with existing staff?

    Is there a need for a health educator on staff or person who can serve as liaison with school administration and/or community?

    Does the SBHC have sufficient staff to monitor the program implementation and supervise the staff after any initial training?

  • If no, are there good prospects for getting additional supervisory staff?

    Parent Participation and Support

    Is there good/strong parent support for current SBHC clinical/health services?

  • If no, is there any plan/effort to increase parental support?

    Does the SBHC have a track record of parent participation and established relations with parents around child health services?

  • If no, are there good prospects?

    Is there a core group of parents who could serve as an advisory group?

    Are there any plans to involve parents in SBHC prevention activities?

    Community Participation and Support

    Has the SBHC successfully collaborated with community groups in the past?

  • If yes, can the SBHC build on that record in implementing prevention programs?
  • If no, are there good prospects for developing collaborative relationships

    Does the SBHC have connections to the local media so that prevention messages could be reinforced through appropriate media channels?

  • If yes, are there any plans to use this capability in selecting prevention programming?
  • If no, are there good prospects for developing those connections?

    Are after-school activities such as community social groups, job opportunities, and intra- or extra-mural programs available for kids?

  • If no, are there good prospects for establishing connections with those activities?

    Program Monitoring and Assessment

    Does the SBHC have the capacity for monitoring and assessing prevention programs, activities, and student outcomes?

  • Does the SBHC have (access to) a personal computer(s)?
  • Does the SBHC have a management information system (MIS) in place?
  • Is the school wired for the internet (i.e., on-line)?
  • Are SBHC staff resources available to input, monitor, and review behavioral change data and student outcomes?

    Lessons Gathered

    In the process of assessing its readiness to implement prevention programs, a SBHC may wish to consider some of the experiential lessons of prevention researchers and others in the field. The following section, which is based on discussions with the experts and others in the field, is a synthesis of some of the main lessons learned about implementing prevention programs in schools or SBHCs. These lessons gathered can assist SBHCs in the self-assessment and implementation process.

    Consider the capacity of the SBHC. The types of services and programs SBHCs provide depend on the center’s capacity. Most SBHCs fall into one of the following categories: (1) Those that deliver clinical services alone, (2) Those that deliver clinical services but are also interested in prevention and might require additional trained staff and access to evidence-based programs, or (3) Those that are a vehicle for first-entry into the health care system and students in need of ancillary or prevention services would be referred out to other sources.

    Start with a needs assessment. Assessment of programs actually begins with the decision to implement a program in a particular community. The unmet health needs in the community must be identified, and the current resources, the system to address problems, and the current and potential role of community in prevention programming must be considered in developing and implementing appropriate programs.

    Prevention programs are needed at all stages of the developmental process. Most prevention scientists would agree that there is a need for prevention programs at all stages in the developmental process-- from early childhood through adolescence. Therefore, SBHCs at elementary, middle and high schools can all implement programs for the level of students they serve. The benefits of intervening with younger kids who are at risk for problem behaviors are that children are more malleable at a young age and certain behaviors that are present in younger children are antecedents to problem behaviors of adolescents. A benefit of intervening during adolescence are that prevention is not like inoculation and that it must be continued through childhood and into early and late adolescence.

    Define the target group and program type. Services can be provided on a universal, selective, or indicated level, depending on the type of services provided and the delivery mechanism chosen. Universal programs are programs aimed at a general population, such as all children in a school. An example of a universal program would be a curriculum delivered in a classroom with all children receiving the same information. Selective programs target groups at risk or subsets of the general population who have been identified because they possess certain risk factors or because they have engaged in certain behaviors. A selective program might target a smaller group either in a SBHC setting or by identifying students through a SBHC that are considered at risk and targeting the program to them specifically. Indicated programs are designed for populations who are already engaging in risk behaviors, such as sexual activity or drug use. Indicated programs generally provide services on an individual level. The type of program that is most appropriate will depend on the prevalence of the risk behaviors in a given school, staff resources available, and the structure of the school and health system.

    Consider cultural and language differences in target group. Cultural and language differences must be considered when designing or implementing a program, and where appropriate, it should be tailored so that the program content and program delivery are culturally relevant to the targeted recipients.

    Consider the relationship between the school and the other competing forces in the school district. Schools can be an effective place to provide prevention services, but it is important to address the ongoing tension in schools by acknowledging competing interests of the administration, the parents, and the health care practitioners who are all trying to address the academic, behavioral, and health problems facing children and adolescents in schools.

    Consider the organizational structure of the school. Structural features can either facilitate or impede implementation of programs in the schools, and therefore must be addressed when discussing the role and function of SBHCs. These features include classroom organization, decision-making processes, and school grade levels.

    School size can affect students’ performance. School size can be a factor in students’ performance and success in school. Although it is not something that SBHCs can address directly, it an issue that must be considered in the school’s attempts to maximize the potential of its students.

    Other factors in and around school can affect students’ academic performance. Other contextual issues that may affect learning and well-being include the atmosphere of the school, the availability of adequate resources for teachers and students, and the level of safety in the school. A child going to school in a building in which the paint is peeling from the walls and the ceilings are collapsing and armed guards are at the doors would presumably have a different school learning experience than those students who go to a school with freshly painted walls, computers, and flowers planted outside.

    Staff should be aware of what is happening in community. Some of the more macro level problems in communities, such as poverty, drugs and violence can adversely affect students, and it is important for staff in the SBHCs to be aware of the issues that are particular to a given community in order to adequately serve the needs of the population.

    Gain support of the community. Support from key community forces is important to increasing the reach of the SBHC. Such support involves political leaders, community leaders, health and human service agencies, and families. Community groups may help children form attachments to their communities, which may help them establish "structures of meaning" in their lives.

    Children need meaningful life experiences outside of the school. Violence and teen pregnancy prevention cannot be sufficiently addressed without a more community-oriented solution, in which children are involved in activities where they can have meaningful experiences and not get pregnant and not get involved in violence or substance use. With SBHC support, these community-based activities can take many forms, including sports, dance troupes, or other extracurricular activities.

    Consider what technical resources are needed for monitoring programs. There are technical issues involved in conducting a proper evaluation. Schools and SBHCs need specific resources and training to conduct evaluations, including adequate computers for data entry and data management, as well as skilled data analysts.

    Injury or accident prevention may be a first step before behavior change programs. There may be prevention methods that protect kids from injuries and accidents without changing behavior. Barbara Barlow’s campaign to get window bars installed in apartment buildings and her efforts to get safer playgrounds at elementary schools are two methods of preventing injury and death without requiring change in any cognitive process. These types of programs might be a way to start incremental changes while gaining credibility in the SBHC or community setting. These programs should not be a substitute for behavior change programs, but possibly a first step in gaining parental and community support for further activity.