Chapter 4

Ecology, Prevention, and Promotion

 

Chapter Aims

In this chapter, you will learn the definition, rationale, value-base, action implications, and limitations of the following principles that have served as the foundation for the field of community psychology:

1. the ecological metaphor

2. prevention and promotion

In this chapter, we review two of the key principles on which community psychology has been built: (a) the ecological metaphor and (b) prevention and promotion. We elaborate on each of these concepts that we briefly introduced in Chapter 2. These concepts are very important to understand because they constitute the language of community psychology, and language embodies the assumptions and world view of any field. It is through the lenses of the metaphors and principles that we will describe in this chapter that community psychologists view social problems. An important question to ask in examining any conceptual framework is: What is emphasized and what is ignored? This is a question that we will bear in mind as we review these core principles.

THE ECOLOGICAL METAPHOR

What Is the Ecological Metaphor?

The ecological metaphor can be defined as the interaction between individuals and the multiple social systems in which they are embedded. Community psychologist Jim Kelly introduced four principles of the ecological perspective: (a) interdependence, (b) cycling of resources, (c) adaptation, and (d) succession (Kelly, 1966; Trickett, Kelly, & Todd, 1972). To illustrate the usefulness of these principles, we consider the example of the deinstitutionalization of people with serious mental health problems (a problem that we treat in more depth in Chapter 21). From the mid-19th century to the mid-20th century, people with serious mental health problems in western nations were institutionalized in large mental hospitals. Beginning in the 1950s, governments began a policy of deinstitutionalization of individuals who had been hospitalized in these settings. The inpatient populations of mental hospitals shrank dramatically, with hospitals in some locales being closed, and people with mental health problems were discharged into the community (Rochefort, 1993). How do the principles of the ecological metaphor help us to understand this change and its impacts on people and communities?

Interdependence. The principle of interdependence asserts that the different parts of an eco-system are interconnected and that changes in any one part of the system will have ripple effects that impact on other parts of the system. As we noted in Chapter 2, the ecological metaphor draws attention to three interdependent levels of analysis: (a) personal (micro), (b) relational (meso), and (c) collective (macro). All of these levels are interconnected with each smaller level nested within the larger levels (see Figure 4.1). Deinstitutionalization provides a clear example of this interdependence. The closing or downsizing of mental hospitals led to former patients being discharged to poor living conditions in the community, including substandard housing (and growing homelessness for many) and inadequate support services (Goering, Wasylenki, Lancee, & Freeman, 1984). The ripple effects of deinstitutionalization also included uninformed and unprepared communities, with community members often displaying prejudice and rejection rather than welcoming acceptance of people with mental health problems (Dear & Taylor, 1982), and families who were stressed and burdened at having to assume the role of primary care providers with little or no support (Potasznik & Nelson, 1984). Attending to the unintended side-effects of a systems change is one important implication of the principle of interdependence.

Cycling of Resources. This principle focuses on the identification, development, and allocation of resources within systems. One clear finding from the experience of deinstitutionalization is that, with a few notable exceptions, resources were not reallocated from state hospitals into community support and housing programs, as was needed (Kiesler, 1992). Psychiatric wards in general hospitals were created, but these are short-stay facilities. Without adequate support following discharge, people with mental health problems experience a Arevolving door@ of readmission to and discharge from these programs (Wasylenki, Goering, & MacNaughton, 1992). The cycling of resources principle also draws attention to potential untapped resources in a system. Traditionally, society has regarded the formal mental health service system as the resource. However, with deinstitutionalization, non-traditional sources of support have been identified, organized, and used to address the problems faced by people with serious mental illness. These include a person=s social network members, non-professional community helpers or volunteers, and self-help organizations (both for mental health consumers and family members). The cycling of resources principle suggests that the community can be a valuable resource to people with serious mental illness and their families.

Adaptation. The principle of adaptation suggests that individuals and systems must cope with and adapt to changing conditions in an eco-system. In the wake of deinstitutionalization, communities have had to adapt to the insertion of people with ongoing mental health problems into their ranks; community support workers and programs have had to cope with inadequate funding and waiting lists for limited community services; families have often had to become primary care providers; and people with mental health problems have had to contend with stigma, poor housing, poverty, and inadequate support services (Capponi, 1991). When housing, community support, and self-help are available to help support individuals, the potential for recovery of mental health is enhanced (Nelson, Lord, & Ochocka, 2001).

Succession. Succession involves a long-term time perspective and draws attention to the historical context of a problem and the need for planning for a preferred future. There are many explanations for why deinstitutionalization occurred. It is often argued that the advent of  psychotropic medications helped to reduce psychiatric symptoms in this population and hastened their release from hospital, but this is only a partial explanation. Scull (1977) found that hospital downsizing began before these drugs were developed. Alternatively, Scull argued that the rising costs of the institutional care and the development of public welfare system was the major reason for deinstitutionalization. It was becoming less expensive for governments to maintain people with mental health problems in the community than in institutions. However, the resultant problems of deinstitutionalization have created a whole new set of problems, but in a different context. In looking at deinstitutionalization in hindsight, most observers and critics agree that there was very little planning and anticipation of problems. As a result, some 50 years later, communities continue to struggle with how they can adequately house and support people with serious mental health problems to enjoy a desirable quality of life.

Why Is the Ecological Metaphor Important?

Community psychologists utilize an ecological metaphor in its emphasis on people in the context of social systems, because they believe that mainstream psychology has focused too much on individual psychological processes and has neglected the important role that social systems play in human development. Since mainstream applied psychology has focused on individuals, there are many ways of thinking about individuals (psychoanalysis, behaviorism, humanism) and assessing their characteristics (e. g., personality, IQ, and other tests of individual differences). In contrast, the study of social environments is in the infant stages of development. Community and environmental psychologists have been instrumental in beginning to develop ways of conceptualizing and assessing human environments (Linney, 2000; Moos, 1973; Shinn, 1996).  Community psychologists need to understand the pathogenic or oppressive qualities of human environments, those that stultify growth and create problems in living for people. On the other hand, understanding the salutary qualities of environments can help community psychologists in their work with community members to create environments that promote health, well-being, and competence (Cowen, 1994). Community psychologist Jean Ann Linney (2000) has recently reviewed three ways of thinking about and assessing environments: (a) participants= perceptions of the environment, (b) setting characteristics that are independent of the behavior of participants, and (c) transactional analyses of the dynamic relationship between behavior and context. We briefly consider each of these three approaches.

Perceived Environments. Rudolf Moos (1994) and colleagues have emphasized the importance of the social climate or atmosphere of a setting. The key notion with this conceptualization of environments is the emphasis on people=s perceptions of the environment. Most people can think of settings that they have experienced as oppressive and settings that were experienced as empowering. Moos has argued that there are three broad dimensions of different social environments: (a) relationships, (b) personal development, and (c) systems maintenance and change. The relationship dimension is concerned with how supportive or cohesive the setting appears to be. Is the setting experienced as caring and compassionate? The personal development dimension addresses the individual=s need for self-determination. Does the setting provide opportunities for autonomy, independence, and personal growth? Systems maintenance and change is concerned with the balance between predictability and flexibility. Does the setting provide clear expectations, yet at the same time demonstrate an openness to change and innovation? Too much predictability can produce boredom and resentment, because it may reflect rigid authoritarianism and resistance to change. Too much flexibility can produce confusion due to continuous uncertainty and flux. Moos and colleagues have developed self-report questionnaires tapping these three broad dimensions and specific sub-dimensions to assess classrooms, families, community programs, groups, and work settings (Moos, 1994).

Objective Characteristics of Environments. A second approach to the assessment of environments is to examine characteristics of settings that are more objective and independent of the behavior of individuals who participate in those settings. Different types of measures (e. g., observational methods, demographic and social indicator data) are used to assess qualities of environments, such as the physical and architectural dimensions, policies and procedures, and environmental resources. One example of an observational method cited by Linney (1990) is the PASSING approach designed by Wolfensberger (1972) to assess the extent to which facilities for people with disabilities reflect the construct of normalization. Wolfensberger (1972) defined normalization as theAutilization of means which are as culturally normative as possible in order to establish and/or maintain behaviors and characteristics which are as culturally normative as possible@ (p. 28). External observers spend several days observing these settings to come up with ratings on a number of different dimensions, including physical integration of the setting with the community, the promotion of resident autonomy, social integration within the neighbourhood, and many more (Flynn & Lemay, 1999).


Another way of assessing environments is to examine demographic and social indicator information about the community or setting. Such information provides an aggregate description of the characteristics of the individuals residing in the community (age, socioeconomic status, ethnic background) and characteristics of the community (types of housing, crime rates, rates under treatment for different psychosocial problems). An example of how one can use an objective approach to the assessment of environments is provided in Box 4.1.

Transactional Approaches. Linney (2000) describes transactional approaches as those that include both the behavior of individuals and characteristics of the environment. One transactional approach is the concept of Abehavior settings@ developed by Barker (1968). The two main components of a behavior setting are a standing or routine pattern of behavior and the physical and temporal aspects of the environment. There are implicit guidelines of how to behave in behavior settings. For example, a classroom science lesson and gym period are different behavior settings, and the behavior of people in these settings can be better predicted on the basis of the setting than on the characteristics of the people in the setting.



 

Box 4.1

Objective Assessment of School Atmosphere

Rutter, Maughan, Mortimore, and Ouston (1979) used both observational and social indicator/demographic information in a study of 12 inner city secondary schools in London, England. The major goal of the research was to identify characteristics of school atmosphere and to see if those characteristics were related to students= rates of delinquency, behavior problems, academic achievement, and attendance over the three years that they were enrolled in these schools. Some of the measures of school atmosphere were gathered through observational methods. Students had better outcomes in schools that showed a strong academic emphasis, as indicated by the total amount of teaching time, starting the class on time, assigning homework, planning departmental curriculum, displaying students= work, and frequently using teacher praise for students. Other qualities of the school that were related to positive outcomes were good care and condition of the school, encouragement of student responsibility and participation, low teacher turnover rates, and the number of experienced teachers in the school. While the researchers demonstrated an association between school atmosphere and student outcomes, these relationships could be due to other factors, such as the characteristics of the students. To control for this selection factor, the researchers used the method of social indicator and demographic assessment to describe the qualities of the students at the time they entered the school. Students with higher verbal aptitude and who came from higher socioeconomic status backgrounds had better outcomes three years later than those who were lower on these dimensions. But the important finding of the study was that the school atmosphere measures predicted outcomes over and above the characteristics of the students at the time they entered these schools. School atmosphere does make a difference for students.

 

One interesting extension of the behavior settings concept is Barker and Gump=s (1964) theory of understaffing. They asserted that as the size of an organization increases, the number of people available to staff the different behavior settings also increases. Furthermore, they hypothesized that in small organizations, that individuals would experience more invitations and pressure to take responsibility for staffing the different settings compared with large organizations. In a study of high schools, they found support for this theory of understaffing. Students in smaller schools, including students with academic and social difficulties, were involved in a wider range of activities than students in larger schools. This approach to the understanding of environments has important implications for the community psychology value of participation and collaboration. Small, more intimate environments are apt to pull for more participation than larger, more impersonal environments.

What Is the Value-Base of the Ecological Metaphor?

The ecological perspective addresses the value of holism. Western science and ways of thinking about the world have emphasized linear, reductionistic, and fragmented ways of understanding. In psychology, people are broken down into component parts (learning, perception, cognition) and are examined as isolated entities. Moreover, the researcher is a detached, objective scientist who is viewed as independent of the people he or she is studying, and the professional is an Aexpert@ helper. The ecological perspective revives an emphasis on holistic thinking, feeling, and acting, that was evident in Gestalt psychology.


The holistic emphasis of the ecological perspective is also quite similar to the world view of Aboriginal people. Connors and Maidman (2001) assert that the roots of tribal culture lie in holistic thought, which involves Ainterdependence between the environment, people, and the spirit@ (p. 350). In the traditional world view of Aboriginal people, there is a strong emphasis on the interconnection of people with their spiritual roots and the natural environments and on balance and harmony. Aboriginal holistic thinking also incorporates values (e.g., bravery, respect, cooperation) in the form of teachings which guide community members, unlike Western science which claims to be value neutral. The medicine wheel is a symbol of this way of thinking.

This form of thought is often symbolized by the sacred circle or medicine wheel, which contains the teaching about the interconnection among all of Creation. The circle is a symbol that represents the knowledge offered by holistic world-views share by aboriginal people. From this perspective, elements that affect change in a person are simultaneously seen as impacting on the person=s family, community, nation, and surrounding environment. (Connors & Maidman, 2001, p. 350)

How Can the Ecological Metaphor Be Implemented?

Kelly and Trickett have expanded on the four principles of the ecological perspective and have outlined their implications for preventive intervention (Kelly, 1986) and the conduct of research (Trickett, Kelly, & Vincent, 1984). The major implication of the ecological metaphor for research is that research needs to be conducted in a much more collaborative, participatory manner than mainstream psychological research (Kingry-Westergarrd & Kelly, 1990; Trickett, 1984; Trickett, Kelly, & Vincent, 1983). Since community psychology research is carried out in community settings with community partners, it stands in contrast to the mechanistic approach of experimental psychology and other basic sciences that is conducted in laboratory settings in which the variables under study are tightly controlled. Community members and settings are stakeholders in the research, who want to ensure that their needs are met. In community research, people are active participants in the research process, not passive subjects.


Moreover, community researchers are not exclusively detached, objective scientists. They are human beings with interests, agendas, values, and feelings. Community psychologists are passionately concerned about disadvantaged people and social issues; they want to change the world, to make communities more caring and just. We believe that it is important for community psychologists to write more about their experiences and describe their standpoints in their research reports and writings (see, for example, Kelly, Muñoz, & Snowdon, 1979). We elaborate more on the implications of the ecological perspective for community research in Part IV of this book.

Trickett (1986) has identified several implications of the ecological metaphor for intervention. First and foremost, the spirit of the ecological approach to intervention is distinctive. Not only are problems framed in terms of a systemic analysis, but the process of the intervention is one that is participatory and collaborative. Trickett (1986) captures this spirit in the following passage:

The spirit of ecologically-based consultation is to contribute to the resourcefulness of the host environment by building on locally identified concerns to create processes which aid in empowering the environment to solve its own problems and plan its own development. This spirit is concretized in the kinds of activities engaged in by the consultants, which further highlight the distinctiveness of the ecological metaphor. (p. 190)

The spirit of ecological intervention is one of working with people rather than working on people.   

A second implication for community intervention is that attempts to change one part of the system will have side effects on other systems, and that these side effects will often be unanticipated. The ecological metaphor suggests that social change is not linear. Attempts to solve a problem may lead to new problems in another context. The case of deinstitutionalization of people with serious mental health problems cited earlier is an example of this. A third  implication of the ecological perspective is that the intervention should not focus exclusively on the attainment of outcome goals for participants in a specific program. While it is important to see how individuals benefit from programs, the ecological perspective draws attention to goals at multiple levels of analysis. A successful ecological intervention builds the capacity of the setting to mobilize for future action and create other programs. The degree to which setting members participate in and take ownership for the intervention are also important outcome goals.

Fourth, there are implications of the ecological metaphor for the role and qualities of the interventionist. Since ecological intervention is flexible and improvisational in nature, consultants must be able to form constructive working relationships with different partners from the host setting, problem-solve and think on their feet, be patient and take the time to get to know the setting and the people within it, not jump into offering solutions, tolerate the ambiguities and frustrations that inevitably occur in any intervention, help the setting to mobilize resources from within or to identify external resources, be creative, and attend to issues of entry and exit from the setting.

One other implication of the ecological metaphor for community intervention is that the dimension of time is highlighted. The changing nature of eco-systems and human adaptation requires a long-term time perspective. Contemporary social problems have both historical roots and future consequences. When community psychologists examine social issues and problems from an ecological perspective, they consider these issues and problems at multiple levels of analysis and over a long-term time perspective.        

What Are the Limitations of the Ecological Metaphor?

The ecological metaphor has value in providing a systemic and holistic perspective for the understanding of human experience and behavior and it has led to the development of different ways of understanding and assessing human environments. To date, however, community psychology has tended to focus on micro and meso levels, to the neglect of macro level structures and interventions. Twenty years ago, Janet Cahill (1983) pointed out how different dimensions of the macroeconomy have an impact on mental health. Moreover, the macroeconomic trends that Cahill described have worsened since the publication of her article (e. g., larger gaps in income between the rich and poor, greater capital mobility). Inattention to the macro level of analysis is not a limitation of the ecological perspective, but rather a gap in the extent to which community psychologists have focused on larger social structures.

One limitation of ecological and systems perspectives is that in their emphasis on circular causality and interdependence, that they do not take into account or highlight power differences within eco-systems. For example, the phenomena of child maltreatment and violence against women can be understood in terms of an ecological perspective, with multiple layers of influence. But it is also important to recognize that some players have more power than others in any eco-system, and that those individuals who abuse power must be accountable for their actions. Abused women and children are not architects of their abuse. This is why the ecological metaphor needs to complemented with the concept of power (Trickett, 1994).

PREVENTION AND PROMOTION

What Are Prevention and Promotion?

Prevention. Prevention is a concept that has been around for some time. In the 18th century people believed that disease resulted from noxious odours, Amiasmas,@ that emanated from swamps or polluted soil (Bloom, 1984). Improving sanitation resulted in a decline in the rates of many diseases (e.g., typhoid fever, yellow fever) (see Box 4.2). Prevention has its roots in the field of public health. The thrust of public health approach to prevention is to reduce environmental stressors and to enhance host resistances to withstand those stressors. In the case of smoking, public policy could attempt to restrict advertising and sales to young people and programs could teach ways of resisting peer pressure and commercial exploitation. The public health approach to prevention has been very successful in reducing the incidence of many diseases, yet this approach is effective only with diseases that have a single identified cause, be it a vitamin deficiency or a germ. The problem with this approach when applied to mental health and psychosocial problems in living is that very few of these problems have a single cause (Albee, 1982).

 

Box 4.3

The Story of the Broad Street Pump

George Albee (1991) has recounted one of the important stories in the history of prevention, that of John Snow and the Broad Street pump. In London, John Snow determined that an outbreak of illness was traceable to one source of drinking water. People who drank from the well at Broad Street, but not other wells, were the ones who became sick. Removing the handle on the Broad Street pump and providing an alternative water source prevented the disease of cholera. An important lesson from this story is that prevention is possible even without knowledge of the causes of a problem. No one knew exactly what caused cholera, but this did not stop Snow and others from engaging in community action that led to successful prevention outcomes.

 

Community psychologists have taken the lead in translating the idea of prevention into concepts, research, and programs that are applicable to psychosocial and mental health problems. For example, George Albee (1986, 1996) has drawn attention to issue of politics and power in prevention, arguing that prevention should be a basic feature of a just society. Another community psychologist, the late Emory Cowen, has played a pioneering role in prevention theory, research, practice, and training. Many of the leading prevention researchers today were trained by Cowen.

As we noted in Chapter 2, primary prevention strives to reduce the incidence or onset of a disorder in a population, whereas secondary prevention is not really prevention, but rather early detection and intervention. There are three defining features of prevention (Nelson, Prilleltensky, & Peters, 2002). First, with successful prevention, new cases of a problem do not occur. Second, prevention is not aimed at individuals but at populations; the goal is a decline in rates of disorder. Third, preventive interventions intentionally focus on preventing mental health problems (Cowen, 1980). 

A typology of prevention has been promoted by the Institute of Medicine (IOM, 1994).


Universal preventive interventions are targeted to the general public or a whole population group that has not been identified on the basis of individual risk. An example of a universal preventive intervention for physical health is childhood immunization. Selective preventive interventions are targeted to individuals or subgroups of the population whose risk of developing problems is significantly higher than average. A Head Start or other early childhood programs for all children living in a socioeconomically depressed neighborhood is an example of a selective prevention intervention. Indicated preventive interventions are targeted to high risk individuals who are identified as already having minimal, but detectable signs or symptoms, or biological markers, indicating predisposition for the mental disorder, but who do not meet diagnostic criteria. An intervention to prevent depression in children with one or both clinically depressed parents is an example of an indicated preventive intervention. (NIMH Committee on Prevention Research, 1995, pp. 6-7)

Prilleltensky, Peirson, and Nelson (2001) have noted that universal, selective, and indicated approaches to prevention differ in two ways (see Figure 4.2). First, they differ with respect to the timing of an intervention. Universal and selective approaches occur before a problem has occurred, but indicated approaches are used during the early stages of the problem. Second, they differ with respect to the population served. Everyone is served in a universal intervention; only those who are Aat risk@ are served in a selective intervention; and only those who already are showing signs of a problem are served in an indicated intervention. In this book, we use the term prevention to mean primary prevention, which includes both universal and selective (or high-risk) approaches.


Figure 4.2 illustrates how these different types of prevention can be applied to the prevention of child maltreatment. The line that bisects the oval represents the timing of the intervention. The right hand side of the line is the reactive end of the continuum (working with families in which a child has already been abused), while the left hand side of the line represents the proactive end of the continuum (working with families in which child abuse has not occurred). The ovals represented the populations that served by the prevention approach. The large oval indicates that the universal approach that serves everyone; the next largest oval (with broken lines) represents a sub-set of the population (families that are at-risk of abuse); while the smallest oval (again with broken lines) represents an even smaller sub-set of the population (families in which a child has already abused). Whereas clinical intervention focuses on a small sub-set of the population after problems have developed (reactive approach), prevention works with larger segments of the population before problems have developed (proactive approach). See Box 4.2 for an example of program that is quite unique in combining the universal approach to prevention with indicated (early detection) intervention.

 

Box 4.2

The Fast Track Program: Universal and Indicated Prevention

Fast Track is a large-scale, multi-site, multi-component, long-term program that is designed to prevent antisocial behavior in children (Conduct Problems Prevention Research Group, 2000). The program includes a universal social problem-solving and social skills training curriculum that is implemented 2-3 times per week by Gr. 1-5 classroom teachers who were trained and supported by Fast Track staff. A total of 54 schools with over 370 classrooms from four different sites in the U. S. (selected on the basis of above average crime rates) were randomly assigned to the intervention or a control condition. Further program activities for the period from Gr. 5-10 focussed on the transition to middle school and youth involvement in positive community activities and relationships. A multi-stage screening procedure was used to identify behaviorally disruptive children in kindergarten. The indicated program components that were provided to these children and their parents included family group sessions that focussed on developing positive relationships between families and schools, teaching effective discipline and communication skills for parents, child social skills training groups (which were held while parents met with project staff), home visitation and individualized support for parents, academic tutoring to promote reading skills, and peer-pairing sessions in which the children were paired with classroom peers to promote their skills in making friends. The initial results of the evaluation show positive effects for both the universal and indicated interventions. The universal intervention led to low levels of aggression and positive classroom atmospheres, while both parents and teachers reported improvements in children=s social, emotional, and academic skills, improved parenting skills and relationships with the schools, and reductions in conduct problems and special education use.

Health Promotion. Complementary to prevention is the concept of health promotion. Where prevention, by definition, focusses on reducing problems, promotion can be defined as the enhancement of health and well-being. In practice, health promotion and prevention are closely related. For example, universal interventions that promote healthy eating, physical activity and fitness, and abstinence from smoking have also been shown to prevent cardiovascular disease (Pancer & Nelson, 1990). Cowen (1996) identified four key characteristics of mental health promotion or well-being: (a) it is proactive; it seeks to promote mental health; (b) it focusses on populations, not individuals; (c) it is multidimensional, focussing on Aintegrated sets of operations involving individuals, families, settings, community contexts, and macro level societal structures and policies@ (p. 246); and (d) it is ongoing, not a one-shot, time-limited intervention.

Why Are Prevention and Promotion Important?

AAn ounce of prevention is worth a pound of cure.@ AA stitch in time saves nine.@ These clichés get at the heart of why prevention is important. Once problems occur, they are very difficult to treat. Often one problem cascades into another problem. Treatment methods can be very helpful, but many people experience relapse or re-occurrence of problems. Moreover, even if treatments were 100% effective, there are not nearly enough trained mental health professionals to treat all of those people afflicted with mental health and psychosocial problems in living. As we noted in Chapter 1, the prevalence rates of psychosocial and mental health problems far outstrips available human resources in mental health and social services. Albee (1990) has stated that Athe history of public methods (that emphasize social change) has clearly established, no mass disease or disorder afflicting humankind has ever been eliminated by attempts at treating affected individuals@ (p. 370).

Another argument for primary prevention and health promotion is that it can save money in the long-run. Both institutional and community treatment services provided by professionals for health, mental health, and social problems are very costly. The costs of hospitalizing a person for one is hundreds of dollars in most western countries, and it is not uncommon for therapists to charge $100 for an hour of therapy. Some research has documented the cost-effectiveness of prevention programs. For example, a longitudinal evaluation of the High/Scope Perry Preschool, a preschool educational program for economically disadvantaged children living in a community in Michigan in the U. S. found the following:

Compared to the no-preschool group, the preschool group had higher rates of employment and self-support, a lower welfare rate, fewer acts of serious misconduct, and a lower arrest rate. For every dollar invested, the 30-week program returned six dollars to taxpayers and the 60-week program returned three dollars. (Schweinhart & Weikart, 1989)

What Is the Value-Base of Prevention and Promotion?

Prevention and health promotion focus on the values of health and well-being. Many people think of health or mental health in negative terms, as the absence of disorder. But a broader view of health can be framed in positive terms, as the presence of optimal social, emotional, and cognitive functioning within health promoting and sustaining context. According to the Epp (1988) report Mental Health for Canadians: Striking a Balance:

Mental health is the capacity of the individual, the group and the environment to interact with one another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective, and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservation of conditions of fundamental equality. (p. 7)

According to this definition, mental health is defined ecologically in terms of transactions between the individual and his or her environment, not just in terms of qualities of the individual. The value of health, which underlies the concepts of prevention and promotion, holds that health is a basic human right. Article 24 of the United Nations Convention on the Rights of the Child (United Nations, 1991), for instance, asserts Athe right of the child to the enjoyment of highest attainable standard of health,@ while Article 19 asserts that children should be protected from harmful influences on their health: States Parties shall take appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment of exploitation, including sexual abuse.@

How Can Prevention and Promotion Be Implemented?

As we noted earlier, there are two interrelated approaches to prevention and promotion: one focuses on risk reduction for mental health problems and the other on health  promotion (Cowen, 1996, 2000).


Risk Factors, Protective Factors, and High-Risk Approaches to Prevention. Over the past 20 years, a substantial amount of research has confirmed that most mental health problems are associated with many different risk factors. A risk factor is any factor that is related to the occurrence of a problem (Rae-Grant, 1994). Moreover, the effects of risk factors may be exponential. That is, most people can withstand one risk factor without being adversely affected, but when there is a Apile-up@ of risk factors, the impacts may be particularly devastating. For example, Rutter (1979) found a four-fold increase in subsequent rates of psychiatric problems when two risk factors were present in childhood and a 24-fold increase when four risk factors were present in childhood.

Some individuals, however, demonstrate resilience in that they are able to withstand exposure to many risk factors (Cowen, 2000). These individuals have protective factors that help to offset, or buffer, risk factors. For example, a person with a good social support network or good coping skills may adjust well to a stressful life event such as marital separation. Albee (1982) views the incidence of mental health problems as an equation:

Incidence =      Risk factors    =       Organic causes + Stress + Exploitation    

                   Protective factors   Coping skills + Self-esteem + Support systems

The risk and protective factor formulation is ecological and transactional and nature (Felner, Felner, & Silverman, 2000). As Rae-Grant (1994) has shown, risk and protective factors can occur at multiple levels of analysis. For example, risk factors can occur at the individual (e.g., low self-esteem), family (e.g., marital discord or separation), and community (e.g., living in a violent community) levels of analysis. Similarly, protective factors can be individual (e.g., good coping skills), family (e.g., a warm and loving relationship with one parent), or community (e.g., opportunities for socialization, recreation, or skill development) in nature. An example of a selective intervention program is the Prenatal/Early Infancy Project described in Box 4.4.

 

 

Box 4.4

The Prenatal/Early Infancy Project

This project was developed by David Olds and colleagues in 1977 in Elmira, New York, a semi-rural community in upstate New York. This community was extremely economically depressed and had the highest rates of child maltreatment in the state of New York. Nurse home visitors worked with first-time mothers during the prenatal period and continuing until the children reached two years of age. This was a selective or Ahigh-risk@ approach to prevention of child maltreatment, because the women who were selected were low-income, unmarried, or teenaged. The mothers were randomly assigned to the home visit program or to a control group that received transportation for health care and screening for health problems but no visits. The home visits focused on promoting parent education, enhancing informal support, and linkage with formal services. The nurses completed an average of 32 visits from the prenatal period through the second year of the child=s life. The results of the evaluation showed that during the first two years after delivery, 14 percent of the poor, unmarried teen mothers in the control group abused or neglected their children, as compared to 4 percent of the poor, unmarried teens visited by a nurse (Olds et al., 1986). Many other positive outcomes were found for the mothers and their children in the short-term, including the fact that the program resulted in a cost savings. However, it is the long-term findings that are the most striking. In their analysis of the poor, unmarried women, Olds et al. (1997) found that nurse-visited women had higher rates of employment than the women in the control group, as well as lower rates of impairments due to alcohol or substance abuse (41% vs. 73%), verified child abuse or neglect (29% vs. 54%), arrests (16% vs. 90% according to state records), convictions, days in jail, use of welfare, and subsequent pregnancies when the children were 15 years of age. Also, compared with those mothers were in the control group, the children whose mothers participated in the home visitation program had significantly fewer incidents of running away (24% vs. 60%), arrests (20% vs. 45%), and convictions and violations of probation (9% vs. 47%) at age 15 (Olds et al., 1998).

 

Universal Approaches to the Promotion of Health and Well-Being. Over the past few years, there has been more and more of a focus on health and the promotion of well-being (Cicchetti, Rappaport, Sandler, & Weissberg, 2000; Cowen, 1994, 2000; Peters, 1988; Prilleltensky, Nelson, & Peirson, 2001). Health promotion approaches are often provided on a  universal basis to all individuals in a particular geographical area (e.g., neighbourhood, city, province) or particular setting (e.g., school, workplace, public housing complex). Moreover, health promotion is more likely to focus on multiple ecological levels than risk reduction, which is more often aimed at individuals. An example of a universal prevention/promotion program is the Fast Track program described earlier. See Box 4.5 for some of the ways that wellness can be promoted.

 

Box 4.5

Routes to Psychological Health and Well-Being

Cowen (1994) argues that there are several key pathways toward mental health promotion.

1.             Attachment. Infants and preschool children who form secure attachments to their parents and caregivers early in life fare well in later life. Home visitation programs that work with parents and their infants are one example of a strategy to promote attachments.

2.             Competencies. The development of age-appropriate and culturally relevant competencies is another health promotion strategy. School-based social competence (e.g., social problem-solving skills, assertiveness, interpersonal skills) enhancement programs are one promising approach.

3.             Social environments. Another pathway to the enhancement of health and well-being is to identify the characteristics of environments that are associated with health and then to change social environments toward those characteristics that have been shown to be important for well-being. Changing family, school, community, and larger social environments can be used to promote health.

4.             Empowerment. Empowerment refers to perceived and actual control over one=s life, and empowering interventions are those that enhance participants= control over their lives. An empowerment approach stresses the importance of providing opportunities to exercise their self-determination and strengths, so that they are in control of the intervention.

5.             Resilience and resources to cope with stress. The ability to cope effectively with stressful life events and conditions is another key pathway to health and well-being. Life stressors are often seen as presenting an opportunity for growth, if the person has the resources to manage the stressors.

 

What Are the Limitations of Prevention and Promotion?

While in the past prevention in mental health has been ignored or dismissed by psychiatry and the medical profession (e.g., Lamb & Zusman, 1979), more recently the medical profession has become more enamoured of prevention. Recently, psychiatry has broadened the definition of prevention to include Acomorbidity prevention@ (preventing the development of a second disorder when a person already has one disorder) and Arelapse prevention@ (preventing a person who has been successfully treated from having a relapse) (NIMH Committee on Prevention Research, 1995). Stretching the definition of prevention in this way takes the field back toward Atertiary prevention@ and away from true prevention and promotion, as we have defined them. Moreover, the Institute of Medicine=s (1994) emphasis on Aprevention science,@ focuses rather narrowly on the prevention of psychiatric disorders, as defined in the latest version of the Diagnostic and Statistical Manual, through risk reduction approaches. As Albee (1996, 1998) and Cowen (2000) have noted, this focus diverts attention away from non-medical model approaches, such as health promotion, competence enhancement, empowerment, and social change approaches to prevention and promotion.

The Aprevention science@ approach tends to Amedicalize@ and Adepoliticize@ prevention. We are critical of this approach not because we are against science, but because the particular form of science being promoted by the medical profession is very narrow in emphasis. Selective approaches to prevention, which predominate, are often carried out with low-income people because poverty, low social class, and unemployment are one set of major risk factors for many different mental health problems (Keating & Hertzman, 1999; Perry, 1996). Moreover, selective approaches typically address the bottom half of Albee=s (1982) equation (i.e., promoting protective factors), rather than the top half of the equation (i.e., reducing stress or exploitation). Also, programs which promote protective factors  tend to be person-centred or family-centred, ignoring the larger social environment (Febbraro, 1994). One final criticism of prevention as it is currently practised, is that prevention is something that is done by professional Aexperts@ to Aat risk@ people. Professionally-driven approaches may not address what these so-called Aat risk@ people need or want, may be disempowering and create dependencies on service systems, and tend to focus on deficits rather than the strengths of community members.

More recently, some prevention programs, such as Better Beginnings, Better Futures (Peters, 1994) and 1, 2, 3 Go! (Bouchard, 1999) in Canada, have become more community-driven, with residents in low-income communities actively participating in the planning and implementation of prevention programs in their communities. These programs are not only driven by community members, but they are designed to change or create meso level settings in the community to foster the well-being of families and children. Moreover, Nelson, Amio, Prilleltensky, and Nickels (2000) have proposed concrete steps for value-based partnerships in prevention programs, that include processes for inclusion, participation, and control by disadvantaged people in the design of prevention programs (Cameron & Cadell, 1999).

While the direction towards more community-driven approaches is a positive one, prevention needs to move even further towards macro level analyses and interventions. Albee (1986, 1996, 1998) has argued that prevention should be linked to social justice rather than the medical model. A social justice approach to prevention strives to address the causes of the causes through social change efforts. Thus, prevention should not just be focused on changing individuals, families, or communities, but larger social structures in which people and settings are embedded. To translate this rhetoric into action, we believe that prevention should encompass not just programs, but also social policies. Since economic inequality is a major structural cause of psychosocial problems (Cahill, 1983; Hertzman, 1999; Raphael, 2000; Whiteis, 2000; Wilkinson, 1996), policies that strive to reduce economic inequality, such as those practiced in western and northern European countries, are examples of the form that prevention can take at the macro-level (Peters, Peters, Laurendeau, Chamberland, & Peirson, 2001). Not only have countries like Sweden been successful at reducing the level of economic inequality in their society, but as a result the literacy and numeracy skills of children in the bottom economic quintile in Sweden are vastly better than children in the bottom economic quintiles in the U. S. and Canada (Hertzman, 1999). These findings suggest that there needs to be more emphasis on advocating for change in social and economic policies to promote social justice and well-being.

SUMMARY

We conclude this chapter by noting that the principles of ecology and prevention tend to focus on personal and relational values, to the neglect of collective values, on ameliorative rather than transformative change, to surface manifestations of larger social problems rather than  unequal power relations, and to a focus on well-being rather than liberation. Ecology and prevention helped to define and differentiate community psychology from clinical psychology, but they can inadvertently lend support to the existing societal status quo. Nevertheless, ecology and prevention are useful and important principles for community psychology, and that community psychologists can push the boundaries of these concepts more towards the macro level of analysis. Examination of structural causes of human suffering and macro level policy change to reduce economic inequality are ways that these principles can move towards a more transformative agenda.

 

Domestic Violence: An All Too Familiar Story

A young couple immigrated from Portugal to Canada. The man was an automechanic and the woman worked at home doing sewing and embroidery when in Portugal. They came to Canada seeking a better life. The man found it difficult to find a job equal to his training and eventually accepted a job cleaning offices. He initially forbade his wife to work, but as their family grew (3 children), she eventually took a job in a garment factory. A retired Portuguese woman helped by providing child care. In spite of both partners working, the two combined were able to bring in only a very low-income. The man started to blame the woman for encouraging him to move to Canada, for having three children, and for any problems that they were experiencing. Communication between the two became quite strained and the man began to withdraw from the family and spend more time with male friends. The woman assumed responsibility for running the household and for all child care and child rearing. The man became physically abusive to the woman when she started to work outside the home. The woman did not know there was a shelter for abused women in the community. The man left for a week, and when he returned he was unapologetic and remained verbally abusive. The couple began to sleep in separate beds and communicated very little. The woman was too ashamed to tell any family members about the violence.

1. Use the principles of ecology to help you understand what is happening with this couple and  their family in the context of the larger community and society.

2. How could the principles of prevention and promotion be applied to prevent domestic violence and promote family well-being?

 

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