Transcript Public Prevention Policy

Presentation to the
California Prevention
Collaborative Summit
The IOM Model and its Implications
for Prevention Planning
Presented by
Joël L. Phillips
Center for Applied Research Solutions (CARS) &
Community Prevention Institute (CPI)
April 25, 2006
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Purpose of the Workshop
1. Introduce a historical perspective on the
development of the IOM model.
2. Understand the components of the IOM
model dealing with prevention
(Universal, Selected, Indicated)
3. Examine each of the three IOM
prevention components and how they
can be used in planning prevention in
your community.
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Prevention:
New Directions in Definitions
Prevent: “Keep something from happening”
However, different notions about what that
something is:
– First Incidence (Use)
– Relapse
– Harm (Consequences)
– Risk Condition Itself
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Prevention:
New Directions in Definitions
Prevention rooted in public health field.
(100 years)
– Concern stopping infectious diseases.
Codified in 1957 – “Commission on
Chronic Illness.”
– Introduced the terms:
Primary
Secondary
Tertiary
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Definitions
Primary Prevention:
– Reduce incidence of a disorder (occurrence of
new cases)
Secondary Prevention:
– Reduce prevalence
(that is total number of new and old cases)
Tertiary Prevention:
– Reduce the Sequelae and complications
arising from the problem/disorder once it is
manifest.
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The Traditional
“Public Health” Model
What is the nature/typical history of the behavior?
Situations Linked
to Health
Consequences
Early
Manifestation of
the Behavior/
Condition
Outcome: Total
Manifestation of
Behavior/
Condition
Critical Point 1
Critical Point 2
Critical Point 3
Primary Prevention
Secondary Prevention
Tertiary Prevention
(Prevention)
(Intervention)
(Treatment)
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Assumptions with this Model
Causal pathways can be identified.
– Identify specific agents/vectors of disease.
– However, not so easy in behavioral/ social
science.
Early manifestations the problem/
condition itself is actually preventable.
– However, not so easy to demonstrate.
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Problems with the Model
Health/Disease Focus
Research demonstrates complexity of the
association between risk factors and
health outcomes.
– Biological, psychological, social biophysical
factors
Knowledge about the actual intervening
mechanism still not completely known.
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Conclusion
This model with its origin in
medical science & linear
assumption of causality is less
relevant for those working in nonmedical settings
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Development of Universal/Selected/
Indicated Approach for the AOD Field
Three Steps in the Process
First: R. Gordon. 1982, 1987 –
presented model considering
prevention by population and risk.
Used the Terms:
–Universal
–Selected
–Indicated
Focus: Still on Health Consequences
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Development of Universal/Selected/
Indicated Approach for the AOD Field
Second: Institute of Medicine (IOM). In a
major publication in 1994, (“Reducing
the Risk for Mental Disorder: Frontiers
for Prevention Intervention Research”
Patrick Mrazek and Robert Haggerty
(eds).
Presented the full Continuum of Care
Model:
Focus: Mental Health
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Development of Universal/Selected/
Indicated Approach for the AOD Field
Third: Approximately 2000, CSAP adopts
language – mandates use by states
(2003)
Focus: Substance Use/Abuse
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IOM Approach Assumes
1. The possibility to ‘prevent’ the
occurrence of a health consequence –
and that this can occur anytime.
– Before ‘onset’ of the behavior/condition
‘during’ and with an individual experiencing
the ‘full effect’ of the behavior/condition.
2. Different strategies and approaches to
‘prevention’ will be needed – depending
where in the continuum you want to
address the behavior/condition.
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The Continuum of Care
Protractor
Different levels of prevention are distinguished by the level of risk
of disorder/distress in various populations groups targeted.
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Definition of IOM Prevention
Components
Universal Prevention Measures:
– Address the entire population.
– Aim is prevent/delay use of AOTD. Deter onset by
providing individuals with information/skills
Selected Prevention Measures:
– Targets subsets of the population considered at risk by
virtue of their membership in a particular segment of the
population.
– Key selected Prevention targets the entire subgroup
regardless of the degree of risk of any individuals in the
group.
Indicated Prevention Measures:
– Targets individuals who are exhibiting early signs or
consequences of AOD use.
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Merging ‘old’ definition of
Prevention with IOM Approach
Universal
Average Risk Status of
Population
Average Need for
Prevention
Selected
Increased risk status as a
function of group/class risk
– Increased need for
prevention
Target Condition
Complications
Behavioral Manifestation
Implications for
Intervention
Direct, Indirect Efforts
Implications for
Treatment
Indicated
High risk status or a
function of individual risk
factors
- High need for prevention
Primary Prevention
To reduce new cases
(Incidence)
Secondary Prevention
To reduce existing cases
(Prevalence)
Tertiary Prevention
To reduce complications
(Treatment) 16
Some thoughts about IOM
Advantages:
1. Breaks from a causality model of use.
2. ‘Spectrum of Intervention’ model places great emphasis on
the importance of prevention.
3. Introduces concept of risk management – importance in
knowing proportion of population at risk in turn means most
appropriate prevention strategies can be used.
4. In turn, this sets up potential for strong evaluation results.
Disadvantages:
1. Driven by focus on illness rather than on enhancing
‘wellness.’
2. Emphasis on individuals/populations (less so on
communities).
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Universal Prevention
1. Targets an entire population
National
Local
Community
School or Neighborhood
2. Purpose is to deter the onset of substance use
by providing the population with information
and skills to prevent the problem. The entire
population is considered at risk.
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Steps in Developing our IOM Prevention
Program for Universal Populations
Group Exercise 1
1. What Universal Populations do we want
to focus our prevention efforts on?
 Identify Universal populations
2. What prevention approaches might we
use?
 Identify different approach
3. Why were these approaches selected?
 Alignment issue
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Selected Prevention
1. You are at risk by virtue of membership in a
particular segment of the population vulnerable to
AOD abuse
CSAP examples:
– Children of Adult Alcoholics (COA’s)
– Students who are failing
– Youth who live in high drug use neighborhoods
2. Strategy/Approach targets the entire subgroup,
regardless of the degree of risk of any individual
within the group.
– Participants are not assessed for specific
individual risk factors, but are recruited/referred
based on their membership.
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Potential Selected Populations
Homeless
Young Offenders
Foster Youths
Drop-outs
Students with social/academic problems
Rave party-goers
Others
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Factors for Creating Prevention
Programs for Selected Populations
Identification of subpopulation:
– Clear/difficult
Setting and Access
Alignment:
– Needs of the subpopulation and the proposed
prevention approach/strategy must align
One Example – Foster Youths
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Foster Youths – A Vulnerable
Population Selected → Indicated
Approximately 90,000 in Foster Care in
California
Prognosis for Positive Future – Grim
– 50% do not graduate from high school
– 1 in 8 graduate from a 4 year college
– Only 38% are fully employed 12-18 months after
leaving program
– Median salary less than full-time worker making
minimum wage
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Foster Youths – A Vulnerable
Population Selected → Indicated
– 1/3 of youths leaving foster care experience
Emotional and Behavioral problems including:
Truancy
Social Withdrawal
Running Away
Engage in Risky Behaviors
– 50% use drugs
– 25% have encounters with CJS
– Higher birth rates among young women
(40-60% within 12-18 months leaving the
system)
– Many experience homelessness
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Steps in Developing our IOM Prevention
Programs For Selected Population
Group Exercise 2
Identification of Subpopulation
– Is this an appropriate subpopulation?
– Issues – Selected or Indicated or both?
Setting and Access
– Where to go, Who to partner with?
What types of Prevention Approaches might we
consider
– Who should we target?
– What approaches should we consider?
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Indicated Prevention
1. Targets individuals who are exhibiting early signs
of substance abuse and other problem behaviors
associated with substance abuse including early
substance use.
–
Examples:
Binge drinkers, High rate users
2. Strategy/approach must have screening process
or other identification processes in place to
identify these individuals.
–
The approach involves direct intervention but not
formal treatment
3. Most ‘indicated’ are part of a selected
subpopulation group.
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Factors for creating Prevention
Programs for the Indicated Population
Identification:
– More difficult/complex than selected.
Access:
– Will vary, more difficult than either universal or
selected.
Approaches
– Individualized
– Costly
– SAP’s represent possible approach for in-school
populations.
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Steps in Developing our IOM Prevention
Programs For Indicated Populations
Group Exercise 3
1. What indicated populations in our community do
we want to focus our prevention efforts on?
– Identify Indicated populations.
– State why they are indicated.
– Where would we find them?
2. What Indicated prevention approached might we
use?
3. Why were these approaches selected?
– Alignment issue
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IOM Prevention
Circles within Circles
Selected
Subgroups
Universal Populations
Indicated
Individuals
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Intensity Versus Degree of Risk
Intensity of Intervention
High
Indicated
Moderate
Selected
Universal
Low
Low
Moderate
Degree of Risk
High
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Summary
IOM approach requires:
Better understanding of our community –
communities within communities.
Tired approach in thinking about prevention
services.
– U.S.I
Thoughtful application of prevention approaches
to the three types of populations.
But it gives us:
Better focus on AOD problems and individuals
involved/impacted by AOD use.
Potentially better measurements of success.
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Conclusion
Use the IOM model to define and target
populations in need of prevention services.
– Determine whether you are dealing with a Universal,
Selected, or Indicated populations and what type of
problem/condition they are (or could) experience.
– Approaches that specifically meet the needs of the
populations and AOD conditions of concern.
Identify potential collaborators/resources to
engage in the prevention approach.
Develop a specific prevention plan for
implementing the primary prevention plan.
Maintain and evaluate prevention outcomes.
Target, target, target.
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This document is a product of the Community Prevention Institute (CPI),
a project of the Center for Applied Research Solutions (CARS), to
provide no-cost technical assistance and training to communities
throughout California. CPI is funded and directed by the California
Department of Alcohol and Drug Programs.
For more information about CPI, go to:
www.ca-cpi.org or www.cars-rp.org.
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