Prevention Programs

Urban Institute Project Report

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

CHAPTER FIVE

From Research to Practice: Some Next Steps

We began the inquiry by asking whether there are effective prevention interventions that could be used by "prevention-ready" SBHCs to address the risk behaviors that cause health problems in children and adolescents. Our review substantiates that there are many effective intervention programs available, but this report is unique in that it explores the potential of implementing these effective programs in schools and SBHCs. Given the rapid proliferation of SBHCs around the country and their unique ability to reach students who are difficult to reach through more traditional health settings, the SBHC may well be an effective mode of delivery for prevention programs. In fact, SBHCs might be one of the best hopes for reaching the increasing number of children in need, especially at a time when the health care system is unlikely to finance or provide prevention services.

Although there is a set of programs that work and many of them are school-based or could be adapted to school settings, SBHCs must become aware of effective programs and be provided with the appropriate instruments and technical assistance to implement the programs. Currently, there is a wide gap between prevention research and practice in school-based and SBHC settings. This report is a first step in bridging this gap. Parts of the report and future documents and instruments that we propose in this next section could be useful in bringing well-designed, carefully evaluated, and effective prevention programs to those working at SBHCs.

After we answered the question regarding the existence of successful programs, we attempted to answer a related one posed by a RWJ Vice President at one of the project meetings: "Are SBHCs an appropriate vehicle for delivering these sorts of behavioral risk prevention programs?" Based on what we have learned about effective prevention interventions and about SBHCs, including their potential to develop collaborative relationships with schools and communities, the answer is a provisional "Yes." However, SBHCs are going to require the continuing financial support from outside sources, such as state health agencies and private foundations. In addition, the SBHCs will likely need technical support and expert consultation on a variety of financial issues and research dissemination, implementation, and monitoring issues.

Next we asked whether SBHCs interested in expanding their prevention programming from health services to health risk behaviors, are presently prepared to do so, even if they already know that relevant and appropriate programs are available. Here, the answer is more complex and even less assured because we did not talk with or visit a sufficient or representative sample of SBHCs to pose these questions directly. Nevertheless, based on the visits and common experiences of our Advisory Panel, the Prevention Scientists, and UI staff members, as well as the discussions generated by the visits, it seems likely that SBHCs will need some assistance.

Given this conditional response, the next question was whether we could help SBHCs determine what they would need to know about their own developmental stage, about their clients, about the context/ecology of problem behavior prevention, and existing prevention programs, as well as what they would have to do to become "prevention-ready." Based on discussions with our expert panel and meetings with the prevention scientists, we compiled a set of readiness concepts in the form of a SBHC checklist. The Prevention Readiness Checklist is intended to reflect and assess what we think are salient elements/aspects of SBHC prevention readiness.

Thus, the research inquiry and the three tangible products that resulted--the Program Descriptions, the Research Synthesis, and the Prevention Readiness Checklist--constitute a good "first step" toward SBHCs positioning themselves to help provide effective, high quality, prevention programs within a stable financial support system and a collaborative Center/School/Community framework.

The final question this report must address is only partly rhetorical: What are some good "next steps" that could help ensure that many SBHCs will fulfill their prevention potential?

(1) The three study products contained in this report (the Program Descriptions, the Research Synthesis, and the Prevention Readiness Checklist) would benefit from review by SBHC leaders, staff, school health colleagues, and perhaps, by students/clients of SBHCs.

(2) The program descriptions, journal abstracts, and information on the program contacts and availability of the curriculum materials and training can be disseminated immediately to SBHCs and affiliated organizations via the websites of Making the Grade and The Urban Institute.

(3) The draft "Prevention Readiness Checklist" can be disseminated to SBHCs and affiliated organizations. Comments and suggestions for revision could be invited/solicited directly, through e-mail, or by placing a version on the Web and soliciting near real-time revisions and additions.

(4) Once basic revisions to the Checklist are made, the instrument can be "beta tested" to determine its usefulness in a number of SBHCs (perhaps 5-10) that are motivated to expand their prevention programming. As an extension of this idea, Technical Assistance (TA) could be provided to interested SBHCs. Differences in the utility of the Checklist between Centers receiving and not receiving TA could be determined.

(5) A Technical Assistance Resource Center (TARC) could be established on a pilot basis to help strengthen prevention readiness assessment, and if/when SBHCs are ready, to help with program implementation, and assessment of programs.

(6) A SBHC "Needs Assessment Instrument" could be developed or modified from needs assessment instruments and materials available in other settings (e.g., community health or mental health centers) to determine student, parent, school, and community needs around problem behavior prevention, as an initial step in the prevention readiness process. Similar to the process used in the Prevention Readiness Checklist, revisions could be made based on comments and feedback from people working in the field.

(7) Similar to the process described for the Prevention Readiness Checklist, the "Needs Assessment Instrument" could be "beta tested" to determine its usefulness in a number of SBHCs (perhaps 5-10) that are motivated to expand their prevention programming. As an extension of this idea, Technical Assistance (TA) could be provided to interested SBHCs. Differences in the utility of the Checklist between Centers receiving and not receiving TA could be determined.

(8) For a small set of SBHCs (e.g., 4-6) that make a passing score on the Needs Assessment Instrument, a "research to SBHC-practice" pilot program can be developed and funded (by RWJ or other interested foundations) during a 2-3 year period to help SBHCs select, modify, implement, and monitor successful interventions from the study list. Technical Assistance can be provided through the TARC and cover program selection, modification, implementation, and monitoring activities. The implementation and monitoring can be conducted in a process evaluation framework that focuses on monitoring: (1) implementation fidelity to the (modified for SBHC) program content and delivery methods, (2) the amount of student exposure to the program, and (3) changes in student behavior from pre-intervention (baseline) to immediately after the intervention is completed. The pilot work would not be a formal outcome evaluation; no comparison program or group need be involved.

The intent of the program monitoring would be to determine the feasibility of implementation in a SBHC setting and to associate the students' behavior change from preintervention to postintervention, if any, when the program was adapted for use in a new setting. If there is poor implementation or students' behavior does not change, then decisions about modifying or discontinuing the program can be made with (or without) TARC consultation and feedback. If the program "takes hold" in the SBHC setting, then decisions can be made about doing a full-scale comparative outcome evaluation or obtaining sufficient funds to help the successful program become institutionalized.

Based on our findings, we believe that the time is right to begin building and strengthening the linkage between prevention research and school-based practice. It is our hope that the three main study products contained in Chapters 2-4 can be of immediate and longer-term value to the SBHC field and its supporters, although their ultimate value may be best explored and strengthened through a set of next steps, such as those presented above, as well as others yet to be determined. In our view, private foundations such as the RWJ Foundation, can significantly contribute to the building and strengthening SBHC-based prevention programming through their continuing support of the sorts of "next steps" presented in this document.