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Prevention and wellness practices in a 21stcentury environment; what we have and what we need

January, 2012

Author: Frank G. Magourilos, MPS, CPS, ICPS

Big Picture—in the last two decades the science of Behavioral Health Prevention has

advanced faster than our ability to systemically fund, absorb, and effectively utilize. We

finally understand through empirical supportive evidence, that in order to prevent and

reduce societal ills we must start early and well before the onset of the condition1.

Furthermore, we know that to really change the trajectory of any behavior we cannot only

work on the individual but we must also work to change the environment that the individual

lives in23. Given the notion that we have to work within the system of the individual along

with the system of the environment that also includes society as a whole, this provides the

prevention workforce incredible challenges. Clearly prevention, evidence-based,

successful prevention, is a very multifaceted ever changing construct which has certain

characteristics that not only prevention professionals need to understand but it is critically

important that society as a whole, organizations, management, and political leadership

need to also be aware of.

Evidence-based prevention characteristics—the field of prevention is immersed in a

disciplinary approach that utilizes many theories and models from many other sciences

such as; psychology, sociology, public health, and environmental sciences. Because a

human being and their environment are extremely complex systems45 the need for

academic professional prevention workforce development is paramount; yet the current

global prevention workforce system is one that allows individuals to enter the field with

nothing higher needed in most cases than a high school diploma. The skills and

competencies that are needed for today’s prevention professional to be successful are

daunting to say the least. Today’s prevention workforce to be effective needs to be well

versed on concepts, theories, and models such as; risk and protective factors theory6,

systems thinking, logic models, geo-political environments, issues, and policies, strategic

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planning, evaluation, facilitation skills, cultural sensitivity, behavioral models, sociology and

community engagement, mental health and abnormal behaviors, drug categories and

individual drug analyses, diffusion of innovation theory7, leadership theories,

developmental models and aging, social norms8, media and marketing strategies, gender

health and prevention, environmental approaches, integration principles, relationships

between substance abuse prevention and injury and violence prevention9.

The list can go on but I think my point is made, which glaringly eludes to the tremendously

extreme disparity between the degree of high, large, positive prevention results that are

expected from the public, managers, departments, politicians, organizations, local and

state governments, versus the reality of having a prevention workforce that is largely and

extremely ill prepared, under educated and under funded by hundreds of millions of dollars

just in New Mexico alone10. Under the current conditions how can we expect population

level change prevention results in underage drinking, DWI, drugs, and other risk categories

when Prevention funding has decreased by 61% (NM/BHSD/OSAP) in the past two years

in New Mexico? Furthermore, the average pay of our New Mexico prevention workforce is

less than 15 dollars per hour. Most do not have a bachelor’s degree and only one or two

have a degree specific to prevention. If a farmer planted seeds and never watered or

cultivated them would he be surprised at the results? It is quite apparent by the impossible

unfunded and under resourced demands put on the current prevention workforce, that our

leaders, funders, local governments, and many others do not understand why we are not

getting the results we all want.

Systems thinking; how other systems influence prevention—Systems thinking11 is the

process by which we attempt to expose the conditions supporting the problem or symptom

rather than merely reacting to it. Systems’ thinking considers all the intricately woven

factors and influences imposed upon the problem, issue, or opportunity and allow

examination of how each relates to the other and interacts as a whole. Rather than

breaking a problem or opportunity into small pieces and then isolating the pieces in order

to study them, arguably it is more useful to study the entire problem or prospect. In this

way patterns, trends, and systems emerge providing an opportunity to consider both the

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intentional and unintentional consequences of actions to be taken. It is far easier to get

caught in the reactive trap of addressing symptoms when one is focused on a small part

without the context of the bigger picture. What is important to understand is that

everything that we do in prevention is positively or negatively influenced by other systems

in our world that we may or more than likely may not have control over. Prevention is a

system, a school is a system, a government is a system, a family is a system, a community

is a system, a city is a system, politics in itself is a system, identified resources is a

system, networking partners is a system, a DWI Planning Council is a system, the Board of

County Commissioners is a system, and media is a system, just to name a few. All these

systems are open, perpetually changing, and interconnected; every time anything is

changed at any one system it affects all the other systems. These relationships need to be

understood and prevention strategies need to maximize any positive relational influences

that exist between systems while minimizing negative relational impacts to the extent

possible.

Prevention landscape needs a paradigm shift—as mentioned earlier and based on

empirical evidence there are many areas we need to work on if we really care to see

individual and population level change for a better future of our youth, elders, and all

members of a 21st century society. Below is a list of areas that need our immediate

attention:

Flavor of the month approaches—we have the tendency of collectively over reacting to

any new trend that comes along without strategically thinking the impact funding and other

resources would have by diverting from one area of prevention, such as curbing underage

and binge drinking to addressing for example prescription drug abuse; these tendencies

have a huge impact on the overall prevention landscape. A few years ago Meth was a

huge flavor of the month, currently it is prescription drugs, and other trends come and go.

Although I am not advocating that these trends not be addressed, my point is that our

prevention strategies have to be largely based on CORE-ROOT CAUSES while utilizing

risk and protective factors theory and other relevant research based principles. Just by

placing a huge amount of our resources on any one single trend we miss the big picture,

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which are the underlying reasons (individual and environmental) as to why youth and

others are looking to involve themselves in such ill, destructive behaviors in the first place.

Coordinated Statewide Prevention—although an argument can be made for having local

community level control of prevention programs, the research12 points out that unless there

is a central statewide entity, that may not necessarily control the funding, but rather

coordinates and guides prevention efforts, there will always be the silo effect of individual

programs working in segmented areas without cohesive, and collective system-wide

guidance, while always subjected to the mercy of uninformed community politics and

individual agendas. The local needs can always be met by having effective and research

based on-going community assessments13. A comprehensive needs assessment is the

critical first step a coalition or organization must take in order to develop an effective and

successful prevention effort. Furthermore, a comprehensive needs assessment achieve

results because the solutions are targeted at the real causes. By having a coordinated

statewide prevention effort many benefits would be realized:

• Partnerships between programs facilitate the sharing of information, materials, and

expertise.

• Integrates and maximizes resources.

• Facilitates complementary and supplementary programs.

• Leads to a system in which the whole is greater than the sum of its parts.

• The benefits of coordination are compelling and beneficial to the public.

• Increased capacity and improved quality of services to individuals and communities

because of shared knowledge and improved planning.

• Statewide prevention coordination largely eliminates political agendas, unwarranted

interference, and individual power plays at the local level.

• If there is to be a systems wide prevention integration approach, federal and state

coordination is absolutely critical.

Prevention and systems integration—in June of 2011 the Federal Government released

the first ever National Prevention Strategy14. The National Prevention Strategy’s vision is

working together to improve the health and quality of life for individuals, families, and

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communities by moving the nation from a focus on sickness and disease to one based on

prevention and wellness. This Strategy envisions a prevention-oriented society where all

sectors (systems) recognize the value of health for individuals, families, and society and

work together to achieve better health for all Americans. Aligning and coordinating

prevention efforts across a wide range of partners (systems) is central to the success of

the National Prevention Strategy. Engaging partners across disciplines, sectors, and

institutions can change the way communities conceptualize and solve problems, enhance

implementation of innovative strategies, and improve individual and community well-being.

Health and wellness are influenced by the places in which people live, learn, work, and

play. Communities, including homes, schools, public spaces, and work sites, can be

transformed to support well-being and make healthy choices easy and affordable. Healthy

and safe community environments include those with clean air and water, affordable and

secure housing, sustainable and economically vital neighborhoods (e.g., efficient

transportation, good schools), and supportive structures (e.g., violence free places to be

active, access to affordable healthy foods, streetscapes designed to prevent injury).

Healthy and safe community environments are able to detect and respond to both acute

(emergency) and chronic (ongoing) threats to health.

Making places healthier requires capacity for planning, delivering, and evaluating

prevention efforts. A prevention-oriented society can be supported by integrating health

and health equity criteria into community planning and decision making whenever

appropriate; maintaining a skilled, cross-trained, and diverse prevention workforce;

strengthening the capacity of state, tribal, local, and territorial health departments;

implementing effective policies and programs that promote health and safety; and

enhancing cross-sector data sharing and collaboration. This is the national vision

representing 17 heads of departments, agencies, and offices across the Federal

government who are committed to promoting prevention and wellness14.

Critically important to understand is the significant relationships between interdisciplinary

prevention professionals and all community partners. A wide range of actions contribute to

and support prevention, ranging, for example, from a small business that supports

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evidence-based workplace wellness efforts, to a community-based organization that

provides job training for the unemployed, to the parent of young children who works to

provide healthy foods and ensure they receive appropriate preventive services. Partners

play a variety of roles and, at their best, are trusted members of the communities and

populations they serve. Opportunities for prevention increase when those working in

housing, transportation, education, and many other sectors incorporate health and

wellness into their decision making.

Professional workforce development—arguably, this is the most important area that

needs to be addressed and brought forth to individual and community needs of the 21st

century. Many studies and assessments have been done in this area, and they all point

out the stark inadequacies of the workforce in the field of behavioral health prevention15.

Based on previous reports and reviews, barriers to strengthening the behavioral health

prevention workforce can be summarized as:

• Inadequate knowledge and expertise of the competencies the workforce needs to

meet current and future challenges.

• Lack in Identifying, Classifying, and Enumerating the Public Health Prevention

Workforce:

• Lack of clear, concise, public health prevention profession classification categories.

• A lack of a professional workforce education and expertise in advance

specialization areas and disciplines such as systems thinking, direct services,

environmental strategies, problem id and referral, policy and advocacy, community

private sector, public sector, and volunteer sector engagement.

• An absence of consistent public health professional credentialing requirements.

• Ineffective and inefficient training that mostly includes single-session didactic

workshops.

More critically, recent findings have exposed that today’s members of the prevention

workforce regularly struggle with the ambiguity of the rules, regulations, standards, and

procedures that manage service delivery, and which sometimes conflict with one another.

These rules may also not be grounded in an evidence base. They frequently limit

professional decisions and judgments, and can severely limit efforts to tailor interventions

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to individual need. Productivity is reduced because of administrative burdens, most notably

those involving extensive and often repetitive documentation. Members of the workforce

have repeatedly described their low morale and low levels of commitment to their

organization and to the field because of low pay, the absence of career ladders, excessive

workloads, tenuous job security, and an inability to influence the organization or system in

which they are working16171819.

Workforce potential solutions—we need to expand the current workforce capacity by

utilizing a system or a number of strategies that allow for a very broad-base empirical

prevention knowledge base across multiple disciplines. One way of accomplishing this

would be to infuse prevention core principles into existing curricula for teachers, doctors,

nurses, social workers, psychologists, and other human services professionals. This

would allow new professionals entering these fields to be equipped to utilize evidence-

based prevention practices into their sphere of influence.

There are also numerous prospects for increasing the knowledge base of the existing

human services workforce. Professional associations of teachers, school administrators,

social workers, nurses, doctors, psychologists, child welfare administrators, juvenile justice

administrators, and the public health field as well, can include information on evidence-

based prevention practices within their national conferences and continuing education

training courses. Federal agencies may also want to consider issuing workforce

development planning grants for states that are specifically focused on the area of

revitalizing and intensifying the prevention-based knowledge and competencies of their

workforce.

Cultivate and multiply prevention related partnerships and coalitions—a critical part

of workforce development and expansion needs to come from outside the normal

boundaries of the behavioral health field. There are simply not sufficient financial and

human resources to address such a complex problem as adverse human behaviors and

the environmental factors involved by simply doing what the current prevention field has

been doing; namely a small number of individuals attempting to prevent millions of youth

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and adults from risky behaviors while at the same time trying to stem the environmental

tides of risk factors such as poverty, media, music, Internet, and motion picture glorification

of alcohol, selfishness, and social permissiveness just to name a few. Having said this,

the solution is imbedded in the simple premise that health and wellness, including

behavioral health, is in the best interest of everyone and every sector of our social

environment. Promoting prevention and wellness initiatives are attractive because they

impact all aspects of societal functioning. For example, the case can be made that

businesses should play a vital role in prevention and wellness because it would greatly

influence their bottom line. Healthy and productive young people are a coveted resource

for today’s competitive world. Adults with children that have health insurance with their

employers would arguably have lower healthcare costs thus, reducing the premiums that

have to be paid by businesses. These are just a few examples of cost savings and

incentives for businesses to participate, support, advocate, and even partially fund

prevention and wellness. The same can be said for many other sectors in our

communities (systems); coalitions, clubs, civic organizations, public, private, non-profits,

volunteer, etc. need to be on the table, and a very specific targeted, sustainable effort

needs to take place to bring everyone on-board to infuse prevention and wellness into the

entire social environment.

Leadership—however, in order for such a wide net to be systematically and successfully

dispersed there has to be critical leadership and coordination from federal, state, and local

governmental agencies. The Affordable Care Act enacted in 2010 authorized the creation

of the National Prevention, Health Promotion, and Public Health Council, a body charged

with providing coordination and leadership at the federal level among executive

departments and agencies in relation to prevention, wellness, and health promotion20; this

National Prevention Council would be the logical place for providing leadership and

coordination in addressing the need for total community engagement, and in fact the

National prevention Strategy released in June of 2011and created by this Council calls for

just that. In addition, we will need to look at existing data systems that can be expanded to

include specific community sectors for process and outcome measures. There will also be

the need to look at available or create new evidence based programs and practices that

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are tailored to each community and business segment. Finally, we will have to look at

creating, improving existing and/or developing a segment of our prevention workforce that

would specialize in wide and far reaching relationship building and partner engagement

from all community sectors.

Another critical area that leadership has to be involved in is the prerequisite to have a

much focused mission and consistent strategy in the robust dissemination of prevention

research findings. From how prevention impacts human developmental stages and what

strategies are effective, to how systems and environmental interactions support or hinder

quality of life. Furthermore, prevention integration models that include cost and benefits

analyses need to be created and disseminated into the many different verbiage and

languages of business sectors and other organizational environments. To apply it

differently, prevention principles, practices, and core foundations will be disseminated

universally, however additional components such as how these principles, practices, and

policies will impact a particular sector of the economy or the social environment should be

disseminated to be understood by using the lingo of such sector it is intended for.

Resources—if there is fruition in the creation and implementation of a coordinated

sustainable prevention and wellness integration into every core and every component of all

the sectors that make up the systems that function as our social environments, then the

additional saved resources from lower health care and societal costs, along with the quality

of life improvements gained, will exponentially eclipse the resources needed to realize,

implement, and sustain this prevention integration systems approach.

Conclusion—clearly if we want to take advantage of the research and the recent

advances in prevention and wellness we have to also work on the implementation and

workforce development side of the equation. The logical place for the spark needed to

lead us into this direction is the National Prevention Council and the Substance Abuse and

Mental Health Services Administration, SAMHSA that has prevention as its top priority21,

their combined leadership would put the nation in a great position to advance prevention

services in all sectors of our social environment. Furthermore, the 2009 Institute of

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Medicine, IOM report27 along with the National Prevention Strategy provide the

foundational 21st century prevention and wellness roadmap to follow. Currently the

infrastructure necessary to broadly and expansively deliver prevention services is not

collectively been constructed, although most pieces already exist. It is time for a paradigm

shift in prevention and wellness, and the tipping point is within reach waiting for leadership

to strike the match.

References 1. Preventing Mental, Emotional, and Behavioral Disorders Among Young People:

Progress and Possibilities http://www.nap.edu/catalog/12480.html

2. Gruenewald, P.J. “Commentary – From the ecological to the individual and back

again,” Addiction, 99:1249-1250, 2004.

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underage drinking: A general overview." In R. Bonnie and M.E. O'Connell (eds.)

Reducing Underage Drinking: A Collective Responsibility, Background Papers [CD-

ROM]. Committee on Developing a Strategy to Reduce and Prevent Underage

Drinking. Division of Behavioral and Social Sciences and Education. Washington,

DC: The National Academies Press, 2004.

4. Hartmut, Bossel, Systems and Models; Complexity, Dynamics, Evolution,

Sustainability. Norderstedt, Germany; Books on Demand, 2007.

5. Meadows, Donella, H., Thinking in Systems; A Primer; Chelsea Green Publishing,

2008.

6. Hawkins, J.D.; Catalano, R.F.; Kosterman, R.; Abbott, R.; and Hill, K.G. Preventing

adolescent health-risk behaviors by strengthening protection during childhood.

Archives of Pediatric and Adolescent Medicine 153:226–234, 1999.

7. Rogers, Everett M. (1983). Diffusion of Innovations. New York: Free Press. ISBN

978-0-02-926650-2.

8. Perkins, H. W. & Craig, D. A. (2003). "The Hobart and William Smith Colleges

experiment: A synergistic social norms approach using print, electronic media and

curriculum infusion to reduce collegiate problem drinking". In H. W. Perkins (Ed.), The

Social Norms Approach to preventing school and college age substance abuse: A

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handbook for educators, counselors, clinicians (Chapter 3). San Francisco: Jossey-

Bass.

9. Hoaken, P. N. S., & Stewart, S. H. (2003). Drugs of abuse and the elicitation of

human aggressive behavior. Addictive Behaviors, 28, 1533-1554.

10. EXECUTIVE SUMMARY Behavioral Health Needs & Gaps In New Mexico,

Page xxvi,

http://www.tacinc.org/downloads/NM/NMGap-Executive%20Summary.pdf

11. Gerald M. Weinberg (2001 - revised) An Introduction to General Systems Thinking.

Dorset House ISBN 0-932-63349-8.

12. Implementing Science Based Prevention; The Experiences of Eighteen

Communities and Progress Towards Inter-Agency Coordination to Reduce Alcohol

and Substance Abuse Among Adolescents Evaluation Report for the Washington

State Incentive Grant (July 1998 – July 2002),

http://www.dshs.wa.gov/rda/research/4/43/overview.shtm

13. Fagan, A.A., Hawkins, J.D., Catalano, R.F. (2008). Using community epidemiologic

data to improve social settings: The Communities That Care prevention system. In

M. Shin (Ed.) Toward positive youth development: Transforming schools and

community programs (pp. 292–312). Oxford; New York: Oxford University Press.

14. The National Prevention Strategy: America’s Plan for Better Health and Wellness,

HHS, 2011, http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf

15. Annapolis Coalition. (2007). An action plan for behavioral health workforce

development: A framework for discussion. Substance Abuse and Mental Health

Administration. Shortage Designation: HPSAs, MUAs & MUPs. Retried on

December 5, 2008 from http://bhpr.hrsa.gov/shortage

16. Institute of Medicine. (2000). To err is human: Building a safer health system (L. T.

Kohn, J. M. Corrigan, & M. S. Donaldson, Eds.). Washington, DC: National

Academy Press.

17. Institute of Medicine (2001). Crossing the quality chasm: A new health system for

the 21st century. Washington, DC: National Academies Press.

18. Institute of Medicine. (2003). Health professions education: A bridge to quality (A. C.

Greiner & E. Knebel, Eds.). Washington, DC: The National Academies Press.

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19. Blankertz & Robinson, 1997b; Center for Health Workforce Studies, 2006; Gellis &

Kim, 2004; Hanrahan & Gerolamo, 2004; IOM, 2003, 2004; Zurn, Dal Poz, Stilwell,

& Adams, 2004.

20. The affordable Care Act 2010,

http://www.whitehouse.gov/healthreform/healthcare- overview

21. SAMHSA’s Eight Strategic Initiatives, http://www.samhsa.gov/About/strategy.aspx

About the Author Frank G. Magourilos is a Sr. Certified Prevention Specialist with a Master’s Degree in

Prevention Science from Oklahoma University and Bachelor’s Degrees in Cognitive

Behavioral Psychology and Intercultural Communication from the University of New

Mexico. He is the Executive Director of the New Mexico Credentialing Board for

Behavioral Health Professionals, www.NMCBBHP.org and he is also the Founder of the

New Mexico Prevention Network, www.nmpreventionnetwork.org. Additionally, Mr.

Magourilos oversees all the Prevention Programming for the Santa Fe County DWI

Program and is a Technical Prevention Advisor for the New Mexico Department of Finance

& Administration Local DWI Programs.