Introduction to Prevention for Public Health Social Workers

Introduction to Prevention for Public Health Social Workers Esther Velásquez, Sc. D, MSW, MPH Social Epidemiologist & Public Health Social Worker

Identify Learning Objectives At the end of this presentation, the students will be able to 1. Appreciate national context for prevention 2. Explain the relevance of prevention efforts for public health social workers 3. Identify barriers to prevention work 4. Describe prevention and intervention efforts as a continuum and classify interventions as primary, secondary, or tertiary prevention 5. Match prevention interventions to the social-ecological level(s) they target 6. Explain the Prevention Paradox; list dis/advantages of High-Risk and Population Strategies 7. Describe current status of prevention in social work

Prevention: The National Context • Approximately 95% of the national health budget is spent on treating diseases, not prevention • Half of all annual deaths associated with preventable conditions • US Health Care Paradox: US spends more than any other nation on healthcare but scores poorly on important measures of health and well-being relative to similar countries, ranking 43 rd in average life expectancy & 51 st in infant mortality rate (Mays& Smith, 2011) (Galea, Tracy, Hoggatt, Di. Maggio, & Karpati, 2011) (Central Intelligence Agency, 2019).

The Rationale for Prevention 1) Ethical: A just society engages in actions that reduce suffering, disease, & death, particularly among its most vulnerable (Albee, 1983) 2) Scientific: Solid body of evidence demonstrates effectiveness of prevention in diverse arenas: violence, substance use, child welfare, homelessness, mental disorders (Cohen, Chavez, & Chehimi, 2010; Hawkins, Shapiro, & Fagan, 2010). 3) Historic: Advances in public health yielded greatest improvements in population-level human well-being in past century e. g. sanitation, vaccination, cardiovascular health, infectious disease control (Turnock, 2007).

Lack of Prevention Creates Inequality “If some groups in the population have different risks of getting ill, it is not sufficient merely to attend to their illness… Otherwise, the burdens and risks of illness will fall differently on different groups and the risk of impaired opportunity for those groups will remain, despite the efforts to provide acute care. ” (Daniels, 2008, pg. 142).

Many Reasons to Invest • Promote health, well-being, and quality of life • Preventing one negative outcome can prevent a domino effect of negative events for that person (e. g. preventing type 2 diabetes can help prevent heart disease) • In some cases, preventing outcome in one individual may yield social & health benefits for others (e. g. preventing suicide reduces contagion effect in family/friends) • Reduce public & private spending on illness • Easier to successfully some conditions than to cure them

Barriers to Prevention • Health care system reimbursement focuses on treatment & “sick visits” • Societal expectation: focus on curing diseases/conditions • Difficulty predicting who is at risk and who will benefit from targeted prevention • Prevention takes time: often no immediate success • Social and health services siloed; failures in often leads to negative consequences in the other (Marvasti & Stafford; 2012)

Prevention Terminology and Examples

Relevant Terminology Scientific discipline of prevention formally recognized in 1980 s, establishing familiar terms for prevention: • Primary, secondary, tertiary Later revisions by Institute of Medicine offered new conceptualization: • Universal, selective, indicated (Mc. Cave & Rishel, 2011) Within social work, both are used!

Prevention as a Continuum Primary Prevention Secondary Prevention Tertiary Prevention • Promote and protect population health • Prevent disease onset or injury incidence • Early detection of health conditions to reduce duration and severity of condition • Reduce impairment, complications, and associated disability Examples: vaccination; emissions regulations Examples: child development assessments; mental health or suicide screening Examples: needle-exchange programs, relapse prevention (Porta, 2014; Aschengrau & Seage, 2013)

Asthma: Thinking Epidemiologically to Lower Rates in Communities of Color “Applying epidemiologic concepts of primary, secondary, and tertiary prevention to the elimination of racial disparities in asthma” (Joseph, Williams, Ownby, Saltzgaber, Johnson, 2006) Primary Secondary Tertiary • Focus on preventing asthma risk factors: obesity, low birth weight, air pollution exposure, access to safe outdoor space for physical activity • Focus on factors that • Focus on racial/ethnic may contribute to disparities in severity of racial/ethnic disparities asthma as measured by in asthma treatment: hospitalizations and need for early death rates; investigate detection, language emergency treatment barriers, knowledge, issues; promote mistrust of health care community-based system, barriers to supports to help quality health care, stabilize after ER visits obesity, exposure to stress and violence

Prevention: Ecological Systems Theory Revisiting Urie Bronfenbrenner’s Ecological Systems Theory Macrosystem Exosystem Chronosystem Mesosystem Microsystem The individual Source: Graphic created by descriptions from Bronfenbrenner, 2005

Prevention at Different Levels An example from the Colorectal Cancer Control Program using the Social Ecological Model Source: Center for Disease Control and Prevention. Colorectal Cancer Control Program (CRCCP). https: //www. cdc. gov/cancer/crccp/sem. html

View “Risk” as a Continuum Social workers frequently use the term “at risk. ” But what does it really mean? Risk defined: “The probability of an adverse event or a beneficial event in a defined population over a specified time interval. ” (Porta, 2014) • The number of risk factors, the severity of risk factors, and the combination of interacting factors influence outcomes • Threshold for distinguishing “at-risk” may be somewhat arbitrary; an individual just below the threshold may be just as likely to experience the issue or disease as someone who didn’t make the cut-off for “at risk”

Rose’s Paradigm: High-Risk Strategy Geoffrey Rose (1926 -1993) was a British epidemiologist known for his work in preventive medicine. What is the “high-risk strategy? ” • Target people identified as “high risk”; address immediate/proximal risk factor • Example below targets those at high risk of dropping out of high school based on high stakes test scores

Rose’s Paradigm: High-risk Strategy Geoffrey Rose (1926 -1993) was a British epidemiologist known for his work in preventive medicine What is the “high-risk strategy? ” • target, high-risk group; address immediate/proximal risk factor

Rose’s Paradigm: High-Risk Strategy Advantages of the High Risk Strategy • large individual benefit to those at risk of dropping out as defined by poor test score • intervention matched to specific students who scored poorly, which increases potential effectiveness • no interference in lives of those deemed low risk • fits into medical model—targets individuals to “cure” low test scores • could be cost effective for high risk group Disadvantages of the High Risk Strategy • low population benefit – not all at risk are identified • labeling of individuals can stigmatize • neglects social factors/conditions contributing to high risk of dropping out • requires high-risk group to engage in “non-normative” behaviors – e. g. be tutored, stay after school, work in a group with “at risk” others • overall control of “issue” or “disease” in population not likely – more high school at-risk cases will emerge if cause of dropping out not addressed • feasibility and cost of screening can be a problem

Rose’s Paradigm: The Prevention Paradox • A large number of people at modest risk may give rise to more cases of dropping out than the small number of people at high risk greater individual risk These individuals may test at lower risk but because larger number of individuals in group, there could be many more cases of dropouts

Rose’s Paradigm: Population Prevention Strategy • Focus on the entire population and shift the risk of the entire population Example: Implement an intervention to shift the standardized test scores of all students in the population; for example, everyone gets intensive test prep

Population Prevention Strategy Advantages of the Population Prevention Strategy • addresses root causes of dropping out (less preparation/learning issues) • large overall population benefit from small individual changes • easier to change and maintain with social norms (everyone is getting test prep) Disadvantages of the Population Prevention Strategy • unintended consequences • changing social norms not easy • costs incurred immediately; but not benefits • impact may not be as expected depending upon distribution of risk • population strategies can widen health disparities (what if test prep doesn’t help “at risk? ”

Rose’s Paradigm Conclusions • Is there still a place for the high-risk strategy? • Yes! Not all outcomes can be addressed feasibly or effectively through the population approach • Ideally PHSW could prevent the causes of negative health and social outcomes, as well as the causes of causes, but must work along the entire continuum

Ethical Considerations • Individual behavior decisions are influenced by complex social & environmental influences • “Expert-driven” prevention efforts may prove ineffective due to unacceptability from target population, or infeasible given local circumstances—time, funding • Consider whether incentives for behavior change are form of coercion • Ensure suggested behavior change is based on solid science (Roberts, 2003)

Evaluation of Whether Prevention Works • Prevention interventions differ from other intervention trials • Randomized control trial is gold standard • But often not feasible for community-based prevention interventions Prevention intervention is haunted by important questions: • How do you measure something that didn’t occur as a result of your intervention? (E. g. students didn’t drop out of high school) • What is success when you can’t “count” anything? • Prevention requires alternative methods for evaluation (see Notes) (Henry, Tolan, Gorman-Smith, & Schoeny; 2017)

Prevention in Social Work Perspectives, Education, and Examples

Prevention in Social Work: Historical Context • Grounded in early work of the 20 th century • Initial efforts demonstrated an understanding of the social determinants of health • Communities were viewed as target populations • Social work emphasis on “person in environment” was linked to prevention • Social work literature began to emphasize prevention and highlight power of the public health (Ruth & Marshall, 2017)

Prevention in Social Work: Current Context By 2000: • Small but growing body of prevention research and practice • Incorporation of prevention and health promotion into NASW practice standards • Proliferation of MSW/MPH programs • Recognition by social work leaders that prevention competencies are core to social work survival as a health profession (Ruth, Velasquez, Marshall & Ziperstein, 2015)

Social Work’s Prevention Paradox • The social work profession consistently articulates commitment to prevention & macro well-being, while paradoxically leaning heavily toward individually oriented solutions focused on diagnosis & treatment • Many reasons: widespread dominance of medical model, pressures that accompanied professionalization, market forces that shaped practice arena for much of 20 th century (Bracht, 2000; Mc. Cave & Rishel, 2011). (Reisch, 2012). • Unfortunate outcome: prevention remains minority practice within social work (Ruth, Velasquez, Marshall, Ziperstein, 2015)

Prevention in Social Work: Drivers & Opportunities • Affordable Care Act: Increased prevention funding; numerous initiatives promoting population health, with many roles for prevention-infused social work (care coordination, navigation, systems integration, integrated behavioral health) (Rishel, 2014) • Increased Systems Focus on SDOH & Unmet Social Needs: Emerging initiatives highlight connections between social work/welfare & health outcomes; require SW to utilize population health approaches & to work across sectors/disciplines to achieve greater impact • SW Grand Challenges: Many focused on health or requiring public health approaches, inter-professionalism, etc. (Ruth & Marshall, 2017) (Cederbaum, Ross, Ruth & Keefe, 2018)

Evidence of SW Increased Interest in Prevention • Increase in MSW/MPH Programs: 45 programs now major method for teaching MSWs about prevention • Increased prevention scholarship in SW journals: articles doubled between 2000 -2010 • Integration of prevention into CSWE EPAS Competencies and NASW Standards of Practice in Health Settings • Emergence of Social Work Health Impact Model: provides map of prevention integration into SW profession (Ruth & Marshall, 2017) (Ruth, Velasquez, Marshall & Ziperstein, 2015) (Ruth, Sisco & Marshall, 2016) (Ruth, Wachman & Schultz, 2014)

Social Work Health Impact Model (Ruth, Wachman & Schultz, 2014)

SW Prevention Competencies Rishel(2014) provides suggested list of prevention competencies for social work: • Explain definition of prevention & different levels of prevention interventions; • Articulate benefits, advantages, & challenges of prevention and advocate for prevention practices and policy; • Apply a risk/protective factor framework to identify those at higher risk; • Identify multiple levels of prevention intervention, drawing on their base in ecological systems theory; • Access, implement, and evaluate evidence-based prevention interventions; and • Facilitate multidisciplinary collaborative prevention efforts

SW Prevention Competencies Rishel provides suggested list of competencies: • Explain the definition of prevention & different levels of prevention interventions; • Articulate benefits, advantages, and challenges of prevention and advocate for prevention practices and policy; • Apply a risk and protective factor framework to identify those at higher risk; • Identify multiple levels for prevention intervention drawing on their base in ecological systems theory; • Access, implement, and evaluate evidence-based prevention interventions; and • Facilitate multidisciplinary collaborative prevention efforts (Rishel, 2014)

Example #1: Social Work and Suicide Prevention Primary Prevention: (promotion of life-enhancing social conditions) • Building/strengthening protective factors e. g. promoting bullying free schools, fostering acceptance of vulnerable people; reducing stress; reducing access to guns; placing restrictive barriers on bridges; building social/community connections Secondary Prevention: (intervening when risk factors are observed) • Early identification of those at-risk via screening; training key people to identify and support; reduce stigma; train professionals to respond correctly; educate media on how contagion containment Tertiary Prevention (once suicidal behaviors are occurring): • Assisting suicidal persons to return to pre-crisis via appropriate mental health interventions; improved coordination of support people/systems; survivor services; community support (Caldwell, 2008)

Sandler’s Suicide Prevention at All Levels of Practice Numerous roles for SW in a comprehensive approach: • Reducing access to lethal means • Enhancing life skills and promoting resilience • Promoting social connectedness • Educating about suicide risk, prevention, terminology, contagion • Helping to destigmatize and increase help-seeking • Ensuring access to mental health care • Identifying and assisting those at risk • Responding effectively to those in crisis • Safety planning • Supporting care transitions & linkages • Learning from Attempt Survivors • Supporting clinician and family suicide survivors • Using technology and other innovations to promote compassionate mental health (Sandler, 2019)

Example #2: Social Work Prevention in Early Intervention What are the goals of EIPP? Who is eligible to participate? Who makes up the EIPP core team of staff? What is the structure of the EIPP program? Please visit the website for additional information: https: //www. mass. gov/early-intervention-parenting-partnerships-eipp Source: Content provided by Beth Buxon, Program Director, LCSW, Maternal Health Initiatives. Massachusetts Department of Public Health, 2018

SW Prevention in Practice: Early Intervention Parenting Partnerships Theoretical background of EIPP: • Life course model • Social determinants of health • Health Equity Model • Trauma-Informed Systems of Care • • Strength-Based Practice Family-Centered Care Attachment theories Dyadic System of Care Three Primary Concepts of EIPP: 1. Focus on the perinatal period. 2. Prioritizing supporting high need families. 3. Promoting healthy parent-child relationships. Source: Content provided by Beth Buxon, Program Director, Maternal Health Initiatives. Massachusetts Department of Public Health, 2018

Photo used with permission of all Early Intervention participants. https: //www. mass. gov/service-details/earlyintervention-parenting-partnerships-eipp-resources

Example #3: SW Prevention in HIV/AIDS Justice Resource Institute Prevention and Access to Care and Treatment (PACT) PACT provides intensive, home-based care to people living with HIV who are having challenges navigating their healthcare and treatment. What are the goals and objectives of PACT? Who is eligible to participate? Who makes up the core team of staff at PACT? What is the structure of the PACT program and what roles do social workers play? Please visit the website for additional information: https: //jri. org/services/health-and-housing/health/pact

Exercise: Evaluating PACT • Would you describe this intervention as primary, secondary, or tertiary prevention? Why? • What social-ecological level(s) does PACT target? • Per Rose’s paradigm, is this a high-risk prevention strategy or a population prevention strategy? • Finally, what are your thoughts about the respective roles of social workers and community health workers as described?

Moving Prevention Efforts Forward in PHSW Specific strategies and recommendations for target areas Education: Integrate prevention into all BSW/MSW programs Research: Extend social work research through collaborative research centers Professional Development: Foster new CE that integrates public health approaches and teaches prevention to practicing social workers Influencing Employers and Funders: Work across sectors and disciplines to advocate for and participate in prevention funding and research

Resources • Berkman, L. F. (2009). Social epidemiology: social determinants of health in the United States: are we losing ground? . Annual review of public health, 30, 27 -41. • Children’s Bureau. Administration of Children and Families. Department of Health and Human Services. What is prevention and why is it important? Retrieved from: https: //www. childwelfare. gov/topics/preventing/overview/whatiscap/#two. • Gottfredson, D. C. , Cook, T. D. , Gardner, F. E. , Gorman-Smith, D. , Howe, G. W. , Sandler, I. N. , & Zafft, K. M. (2015). Standards of evidence for efficacy, effectiveness, and scale-up research in prevention science: Next generation. Prevention Science, 16(7), 893 -926. • Rishel, C. W. (2014). Teaching note—Integrating prevention content into clinical social work practice courses. Journal of Social Work Education, 50(4), 752 -762. • Ruth, B. J. , Velásquez, E. E. , Marshall, J. W. , & Ziperstein, D. (2015). Shaping the future of prevention in social work: An analysis of the professional literature from 2000 through 2010. Social work, 60(2), 126 -134. • Substance Abuse and Mental Health Services Administration, Focus on Prevention. HHS Publication No. (SMA) 10– 4120. Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, Revised 2017.

Resources • Healthy People Curriculum Task Force and the Clinical Prevention and Population Health Curriculum Framework • Blog entry August 8, 2018 "Clinical Prevention and Population Health in Health Professions Education: Tackling the Social Determinants of Health" • Includes 3 case studies along with instructor guides • Association for Prevention Teaching and Research • Case studies • Curriculum guides • Case studies

References • American Psychological Association. (2012). Facing the school dropout dilemma. Washington, DC: Retrieved from http: //www. apa. org/pi/families/resources/school-dropout -prevention. aspx. • Aschengrau, A. , & Seage, G. R. (2013). Essentials of epidemiology in public health. Jones & Bartlett Publishers. • Bronfenbrenner, U. (2005). Making human beings human: Bioecological perspectives on human development. Sage. • Daniels, N. (2008). Just health: meeting health needs fairly. Cambridge University Press. • Fani Marvasti, F. , & Stafford, R. S. (2012). From sick care to health care—reengineering prevention into the US system. New England Journal of Medicine, 367(10), 889 -891. • Haberkorn, J. (2012). Health policy brief: The prevention and public health fund. Health Affairs, 23. • Henry, D. , Tolan, P. , Gorman-Smith, D. , & Schoeny, M. (2017). Alternatives to randomized control trial designs for community-based prevention evaluation. Prevention Science, 18(6), 671 -680. • Joseph, C. L. , Williams, L. K. , Ownby, D. R. , Saltzgaber, J. , & Johnson, C. C. (2006). Applying epidemiologic concepts of primary, secondary, and tertiary prevention to the elimination of racial disparities in asthma. Journal of Allergy and Clinical Immunology, 117(2), 233 -240. • Koh, H. K. , & Sebelius, K. G. (2010). Promoting prevention through the affordable care act. New England Journal of Medicine, 363(14), 1296 -1299. • Kondo, M. C. , Andreyeva, E. , South, E. C. , Mac. Donald, J. M. , & Branas, C. C. (2018). Neighborhood interventions to reduce violence. Annual review of public health, 39, 253271. • Lamm, A. , Harder, A. , Lamm, D. , Rose III, H. , & Rask, G. (2005). Risk factors affecting high school drop out rates and 4 -H teen program planning. Journal of Extension, 43(4), 19. • Porta, M. (Ed. ). (2014). A dictionary of epidemiology. Oxford University Press. Published online 2016 accessed 7/19/18 • Roberts, M. , Hsiao, W. , Berman, P. , & Reich, M. (2003). Getting health reform right: a guide to improving performance and equity. Oxford university press. • Rose G. 1992. The Strategy of Preventive Medicine. New York: Oxford Univ. Press. • Rose, G. , Khaw, K. T. , & Marmot, M. (2008). Rose's strategy of preventive medicine: the complete original text. Oxford University Press, USA.

About the Author Esther E. Velásquez, MSW, MPH, Sc. D is a research specialist in the Science and Technology Platform at Ariadne Labs, a joint health system innovation center of the Harvard T. H. Chan School of Public Health and Brigham and Women’s Hospital. Dr. Velásquez received MSW and MPH degrees from the Boston University Schools of Social Work and Public Health, and a Sc. D in Social Epidemiology from the Harvard T. H. Chan School of Public Health. She is a mixed methods researcher with experience as a clinical social worker. Dr. Velásquez's primary research interest is to apply social epidemiologic research methods to address the social determinants of health inequities.

Acknowledgements • The Advancing Leadership in Public Health Social Work Education project at Boston University School of Social Work (BUSSW-ALPS), was made possible by a cooperative agreement from the Health Resources and Services Administration (HRSA) of the U. S. Department of Health and Human Services (HHS) under grant number G 05 HP 31425. We wish to acknowledge our project officer, Miryam Gerdine, MPH. Thanks also to Sara S. Bachman, BUSSW Center for Innovation in Social Work and Health, and the Group for Public Health Social Work Initiatives • The ALPS Team: • Betty J. Ruth, Principal Investigator bjruth@bu. edu • Madi Wachman, Co-Principal Investigator madi@bu. edu • Alexis Marbach Co-Principal Investigator alexis_marbach@abtassoc. com • Nandini Choudhury, Research Assistant nschoud@bu. edu • Jamie Wyatt Marshall, Principal Consultant jamiewyatt 1@gmail. com