3.D.1
Planning prevention: tiers, risk and what works
ASPPB's competency statement 3.D.1: Plan and implement prevention strategies based on relevant data and research, including evidence for their comparative efficacy and effectiveness, to meet the goals of individuals, couples, families, groups, communities, or organizations
Prevention aims to stop problems before they begin or before early signs become disorders. Planning starts from data on who is at risk and which risk and protective factors can be changed, then chooses a strategy whose evidence fits the goal and the population. The Institute of Medicine framework sorts prevention into universal, selective and indicated tiers. Reviews of effective programs point to features such as sufficient dosage, varied and interactive methods, and a basis in theory.
Key ideas
- Universal prevention
- Offered to a whole population regardless of individual risk, such as every student in a grade or every new parent in a city, without screening anyone in or out (Mrazek and Haggerty, 1994).
- Selective prevention
- Offered to subgroups whose risk is higher than average because of a risk factor, such as a parent's illness or a known vulnerability, before symptoms appear (Mrazek and Haggerty, 1994).
- Indicated prevention
- Offered to individuals with early signs or symptoms that do not meet criteria for a disorder (Mrazek and Haggerty, 1994). Youth depression prevention programs that targeted high-risk individuals, rather than everyone, produced larger effects (Stice and colleagues, 2009).
- Risk and protective factors
- A risk-focused approach identifies the factors that predict a problem and methods shown to change them, then tests those methods in controlled studies with high-risk and general samples (Hawkins, Catalano and Miller, 1992).
- Principles of effective programs
- A review of reviews found effective programs were comprehensive, used varied teaching methods, gave sufficient dosage, were theory driven, fostered positive relationships, were well timed and socioculturally relevant, included outcome evaluation and used well-trained staff (Nation and colleagues, 2003).
Worked example
A university health service has one year of funding to prevent eating disorders among its students. One proposal is a one-hour lecture on warning signs for all first-year students; another is a series of interactive group sessions, led by trained clinicians, for students who report high body dissatisfaction.
- Classify the options: the lecture is universal and psychoeducational; the groups are selective, aimed at a known risk factor.
- Compare the evidence: larger effects have come from selected, interactive, multisession programs delivered by professionals than from universal, didactic, single-session ones (Stice, Shaw and Marti, 2007).
- Check the outcome that matters: dissonance-based and healthy lifestyle programs have reduced the onset of eating disorders in multiple trials, while psychoeducational programs have not (Stice, Onipede and Marti, 2021).
- Plan delivery to keep the effect: in-person groups, voluntary participation, body dissatisfaction as an entry criterion, and clinician facilitators with training and supervision were linked to larger effects (Stice and colleagues, 2019).
Choose the tier and the program from data on risk and from comparative evidence about which strategies change the outcome you care about.
Check yourself
A school screens students and invites those with mild depressive symptoms that do not meet criteria for a disorder into a prevention group. In the Institute of Medicine framework, which tier is this?
Sources
- Institute of Medicine; Mrazek and Haggerty, editors (1994), Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research, Chapter 2, the prevention classification
- Stice, Shaw, Bohon, Marti and Rohde (2009), A meta-analytic review of depression prevention programs for children and adolescents: factors that predict magnitude of intervention effects, Journal of Consulting and Clinical Psychology (PMID 19485590), Abstract; moderators
- Hawkins, Catalano and Miller (1992), Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention, Psychological Bulletin (PMID 1529040), Abstract; the risk-focused approach
- Nation, Crusto, Wandersman and colleagues (2003), What works in prevention: Principles of effective prevention programs, American Psychologist (PMID 12971191), Abstract; the nine characteristics
- Stice, Shaw and Marti (2007), A meta-analytic review of eating disorder prevention programs: encouraging findings, Annual Review of Clinical Psychology (PMID 17716054), Abstract; features of larger effects
- Stice, Onipede and Marti (2021), A meta-analytic review of trials that tested whether eating disorder prevention programs prevent eating disorder onset, Clinical Psychology Review (PMID 34048952), Abstract; programs that reduced onset
- Stice, Marti, Shaw and Rohde (2019), Meta-analytic review of dissonance-based eating disorder prevention programs: Intervention, participant, and facilitator features that predict larger effects, Clinical Psychology Review (PMID 31004832), Abstract; moderators