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Prevention Programs

Urban Institute Project Report

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

EXECUTIVE SUMMARY

Introduction

Despite great interest and effort among policy makers, public health officials, educators, and researchers, the behavioral problems of children and adolescents continue to be a major source of public concern and preoccupation.

A handful of preventable "health risk behaviors" are responsible for much of the mortality and morbidity experienced in adolescence and early adulthood. These behaviors include: regular tobacco use, regular alcohol use, binge drinking, marijuana use, cocaine use, physical fighting, carrying a weapon, suicide ideation, suicide attempt, and sexual intercourse. While the health consequences associated with these behaviors vary considerably, each behavior poses a range of potential immediate and long-term health problems. Moreover, many of these behaviors may co-occur or cluster together in the same individuals, creating greater individual probability of serious negative health consequences.

National data clearly show that the 1990s has been a period of substantial change in students' participation in key health risk behaviors. Regardless of short-term fluctuations in the incidence and prevalence of these individual health risk behaviors, there is overwhelming evidence that many of these problem behaviors are "gateway" behaviors for other and more serious problems. Many behavioral scientists contend that there is a substantial proportion of children and adolescents who are at great risk of not surviving their adolescence-- without appropriate and adequate primary and secondary preventive interventions, as well as remedial treatment services.

Programs designed to target problem behaviors at the primary and the secondary prevention levels have proliferated over the last 20 years. Schools are the major focal point of intervention efforts because they are where most kids are for long portions of their day. Prevention programs are now also pitched at several levels of intervention, including the community, the neighborhood, the peer group, the family/parent, and the individual-- with some notable successes at each level.

Curiously, while there are many successful school-based or combined school- and community-based behavioral intervention programs reported in the literature, school-based health centers (SBHCs) rarely appear as the focal or primary point of attack for the delivery of prevention intervention services. In principle, SBHCs should be a great locus for delivery of primary and secondary prevention interventions to at risk children and adolescents since they already play a unique role in the provision of student health services and already have established access with parents and families. However, they appear to be an underutilized resource. In order for interested SBHCs to play a greater role, there have to be effective problem behavior interventions available for potential use by a "prevention-ready" SBHC community.

Purpose of Report

Given the prevalence of health risk behaviors and the consequences of not addressing them, this report sets out to determine the role prevention programs have played in affecting behavior and the potential role of SBHCs in providing prevention programs. In the following chapters we attempt to provide provisional answers to two fundamental questions: Are there effective problem behavior interventions in existence for interested SBHCs to try? And, if so, what are necessary factors/conditions that must be in place to enable SBHCs to successfully adapt, deliver, and monitor such programs?

Identifying Effective Prevention Interventions

In answering these questions, we look to the literature on preventing childhood and adolescent risk behaviors using a set of rigorous design and impact criteria for program selection. Our major program selection focus was on primary prevention programs that have potential for use in elementary, middle, or high school-based health centers, but we also maintained a focus on identifying interventions that emphasized secondary prevention/cessation of high risk behaviors. For these purposes, we adopted the public health-oriented framework of classifying intervention programs in terms of their intended target audience(s): universal (general population), selective (at risk groups), or indicated (groups already involved in risky behavior) programs.

We were encouraged to identify 51 problem behavior prevention intervention programs that met our selection criteria. The list of 51 programs embodies a set of "best outcomes" in four broad topic areas. It is intended to be analogous to the idea of compiling a list of "best practices" in a given discipline. Problem behavior prevention intervention programs are classified on the basis of two major dimensions-- program content and potential role(s) of SBHCs in program implementation and delivery. Four broad prevention program content areas emerged:

Sexuality/Reproductive Health;
Substance Use;
Conflict Resolution/Violence; and
Mental Health

Three broad prevention program type--SBHC role relationships emerged:

SBHCs could implement and deliver the program independently;
SBHCs and their host school(s) could implement and deliver the program jointly; and
SBHCs, their host school(s), and their communities could implement and deliver the program jointly

We further refined this list for a research synthesis by limiting our in-depth content analysis to programs that met stricter criteria. This selection process culminates in a subset of 21 notable programs, which were examined to "deconstruct" the salient elements. Of these 21 programs:

10 targeted sexual behavior; 8 substance use; 2 child development; 1 mental health (aggressive behavior), but not violence prevention explicitly
18 targeted the universal level of prevention, 1 the selective level, and 2 the indicated level
9 were school-based, multiple component interventions; 6 were school-based, single component; 4 were community-based, child or adolescent focused; and 2 were health clinic-based, adult focused; and
all 21 used an interactive student-teacher (trainer) delivery mechanism--none used an exclusively teacher-to-student didactic (passive) model

Common Program Characteristics of Effective Interventions

Based on our intensive review and deconstruction of program content and delivery methods used in the 21 interventions, we conclude that there are, indeed, important common programming elements among these successful programs. By knowing what characteristics are associated with the most successful programs across program content areas, we hope to gain a greater understanding of what mechanisms are likely to work best in problem behavior prevention generally; and specifically, what are some of the essential elements of effective programs that could be adapted for use in SBHC settings.

We identify six program content and delivery method areas of substantial overlap across the 21 programs:

16 programs (including seven sexuality and all eight substance use programs) use social-learning and social cognitive theories to leverage behavior change (See Chapter 3, footnote 3 for explanation of social learning and social cognitive theories);
14 programs (including eight sexuality and six substance use) have a set of narrowly and clearly articulated behavioral goals;
17 programs (eight sexuality and all eight substance use) have clear and skill-based program components;
20 programs (including nine sexuality and seven substance use) have a written curriculum and provide strong instructor training and feedback;
10 programs (including four sexuality and three substance use) have relatively long duration and intensity; and
10 programs (including three sexuality and four substance use) have multiple component interventions

Interestingly, these six program elements are essentially the same as those noted by Doug Kirby, an expert in sexuality education, in his comprehensive review of sexuality education programs. The programs we reviewed not only represented programs that were methodologically superior and led to positive behavioral outcomes, but also cut across several risk behaviors, including sexuality and substance abuse programs. We feel that these common elements are central to the design and implementation of successful programs.

Assessing Prevention Readiness of SBHCs

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 this study? 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, a group of well known prevention experts (all of whom have made significant programming or evaluation contributions to the prevention intervention literature), the MTG senior staff; and the prevention program coordinators and other staff from two SBHCs visited by UI project staff.

Initially, we intended to conduct site visits at existing programs where promising or successful interventions were being implemented, but we soon realized that the intervention phase had been completed for almost all projects of interest. Moreover, we could not readily locate sites where even the most successful programs were being fully implemented in a new setting. Therefore, we used an alternative approach. We consulted 10 prevention scientists with expertise in sexual behavior, substance use, violence prevention/conflict resolution, or mental health whose own programs had been well evaluated and whose work had moved the field forward. These experts were invited to make site visits to SBHCs in their local areas and to discuss their impressions and share their insights with project and MTG staff and advisory group members with the objectives of assessing the potential for incorporating approaches and programs similar to their own in SBHCs, as well as SBHCs' overall problem behavior prevention prospects.

They 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. Many of them reported that SBHCs need additional information on prevention programs and additional resources and guidance to implement them. Many sites were already providing some level of prevention programming and were interested in ways of expanding their current capacity.

No simple answer to the basic question of whether SBHCs could successfully deliver the sorts of prevention programs identified in our review became apparent. Because of the level of variability found, it was concluded that schools will be at different stages of readiness to do prevention programs. 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 or no additional staff or program 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 a SBHC can be managed, each must consider its stage of readiness to initiate and sustain behaviorally-based prevention programming. The Prevention Readiness Checklist, one of the major products resulting from this research, reflects many of the main contextual and ecological issues that SBHC's face. The main areas covered within the Checklist include:

SBHC development and self-assessment
Needs or risk assessment and program development
Organizational support
Funding
School environment
SBHC staffing
Parent participation and support
Community participation and support
Program monitoring and assessment

What Has Been Learned

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. However, if SBHCs are to succeed in these efforts they are going to require the continuing financial support from outside sources, such as state health agencies and private foundations. In addition, SBHCs will likely need technical support and expert consultation on a variety of financial issues and research dissemination, implementation, and monitoring issues.

We present a set of programs that have been shown to work and many of them are school-based or could be adapted to school settings. School-based health centers must become aware of these effective programs and be provided with appropriate information, instruments, and technical assistance to implement them. 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 as next steps could be useful in bringing well-designed, carefully evaluated, and effective prevention programs to those working at SBHCs.

Another step in the process of bridging the gap between research and practice is to determine whether SBHCs are interested in expanding their prevention programming from health services to health risk behaviors and whether they are presently prepared to do so. The next question is how we can help SBHCs 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 self-assessment 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 have 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.

From Research to Practice: Some Next Steps

The final question this report addresses is only partly rhetorical: "What are some good "next steps" that could help ensure that many SBHCs will fulfill their prevention potential? Here we propose several, including:

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. It may be useful to conduct a series of individual and group interviews to get feedback about the study products, as well as focus groups to gather a range of views and reactions to issues raised in the documents and Checklist. By consulting those working in SBHCs, those working directly with adolescents and children, and those familiar with the risk behaviors explored in this report, more insight could be gained into the factors that facilitate or impede implementation of prevention programs.

The program descriptions, journal abstracts, and information on the program contacts and availability of the curriculum materials and training developed for the report can be disseminated to SBHCs and affiliated organizations.<

The Prevention Readiness Checklist can be disseminated to SBHCs and affiliated organizations in its present draft form for comments and suggestions

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.

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.

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.

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.

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 the RWJ Foundation and/or other interested foundations) during a 2-3 year period. Based on the results of the pilot program, the Foundation could consider funding similar programs or helping successful programs become institutionalized.

Concluding Thoughts

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 the report 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 report.