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American Journal of Community Psychology, Vol. 25, No. 2, 1997 One Small Step for Science, One Giant Leap for Prevention Spero M. Manson University of Colorado Health Sciences Center "Primaiy Prevention Mental Health Programs for Children and Adolescents: A Meta-Analytic Review" by Durlak and Wells (1997) represents a significant benchmark with respect to an empirically based case for the effectiveness of interventions of this nature. In this regard, the authors characterize the general emphases of 177 interventions reported as recently as 1991, summarize their outcomes, place those outcomes within the broader context of other, established treatment and/or prevention efforts in the social sciences and medicine, and suggest future directions for work along these lines. Particularly encouraging is their finding that the average participant in a primary prevention program surpasses the performance of between 59 and 82% of controls, and that the outcomes reflect an 8-46% difference in success rates favoring the former. Perhaps the most telling observation, however, is that these programs yielded significant mean effects comparable to, indeed, in some cases, better than those reported for a wide range of psychological, education, and behavioral treatments, as well as preventive interventions targeting smoking, alcohol use, delinquency, and heart attacks. Previous reviews of the literature had suggested, in tantalizing but less conclusive fashion, that this might be the case (see Coie et al., 1993; Institute of Medicine, 1994; Price, Cowen, Lorion, & Ramos- McKay, 1989). While reading Durlak and Wells's thoughtful manuscript, I found my- self wishing that this had been available to us during the course of the (IOM, 1994) study to which they refer frequently, for it would have facili- tated greatly the arguments advanced therein. However, rather than continue to sing their praises for such an important contribution, which I could, and am sure that others in this issue will do, let me address several specific issues that arise in the article at hand. These issues fall into three 215 009MB62/»7yD400-0215$12.5a/D O 1997 Plenum Publishing Coiporatkm

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American Journal of Community Psychology, Vol. 25, No. 2, 1997

One Small Step for Science, One GiantLeap for Prevention

Spero M. MansonUniversity of Colorado Health Sciences Center

"Primaiy Prevention Mental Health Programs for Children and Adolescents:A Meta-Analytic Review" by Durlak and Wells (1997) represents a significantbenchmark with respect to an empirically based case for the effectivenessof interventions of this nature. In this regard, the authors characterize thegeneral emphases of 177 interventions reported as recently as 1991,summarize their outcomes, place those outcomes within the broadercontext of other, established treatment and/or prevention efforts in thesocial sciences and medicine, and suggest future directions for work alongthese lines. Particularly encouraging is their finding that the averageparticipant in a primary prevention program surpasses the performance ofbetween 59 and 82% of controls, and that the outcomes reflect an 8-46%difference in success rates favoring the former. Perhaps the most tellingobservation, however, is that these programs yielded significant meaneffects comparable to, indeed, in some cases, better than those reportedfor a wide range of psychological, education, and behavioral treatments, aswell as preventive interventions targeting smoking, alcohol use, delinquency,and heart attacks. Previous reviews of the literature had suggested, intantalizing but less conclusive fashion, that this might be the case (see Coieet al., 1993; Institute of Medicine, 1994; Price, Cowen, Lorion, & Ramos-McKay, 1989).

While reading Durlak and Wells's thoughtful manuscript, I found my-self wishing that this had been available to us during the course of the(IOM, 1994) study to which they refer frequently, for it would have facili-tated greatly the arguments advanced therein. However, rather thancontinue to sing their praises for such an important contribution, which Icould, and am sure that others in this issue will do, let me address severalspecific issues that arise in the article at hand. These issues fall into three

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major categories: (a) the marked ethnic and racial diversity of participantsin the studies reviewed, but surprising silence about the implications thatsuch variation holds for understanding program design and effects; (b) theconstrained definition of environment, and general inattention to largerscale, community-based interventions that eventually will force us to rethinkthe conceptual underpinnings of preventive strategies cast within broadersocial contexts; and (c) the distinction between mental health promotionand illness prevention, as anticipated in the IOM report, and with whichthe authors take issue. The discussion of these points is, of course, focusedby the clarity of the findings presented here and Durlak and Wells's carefulinterpretation of them.

ETHNIC AND RACIAL DIVERSITY

Durlak and Wells (1997) point out that nearly half of the studies(48%) did not report the ethnic or racial characteristics of the populationsthat were the targets of the preventive interventions considered in theirmeta-analysis. Yet, they proceed to underscore the fact that in more thana quarter (26.5%) of the samples "either the majority were not white orwere evenly divided between white and non-white populations" (p. 123).Remarkably, this observation occasions no further comment, despite therole that such diversity may play in subsequent analyses of the differentialeffects of the interventions in question.

The IOM report (1994) to which the authors often refer indicatesthat "the evidence is increasingly clear in regard to the link between cul-tural competence and the success (or failure) of preventive interventionresearch and programming (Orlandi, 1992; Neighbors, Bashshur, Price,Selig, Donabedian & Shannon, 1991; Manson, 1982)" (p. 392). Examplesinclude: (a) forging relationships between researchers and community; (b)identifying culturally mediated risks, mechanisms, triggers, and processes;(c) employing culturally consonant theoretical frameworks; (d) preparingculturally relevant content, format, and delivery of preventive interventions;(e) developing culturally appropriate narrative structures and discourse; (f)tapping critical decision-making processes; (g) determining points of inter-vention leverage as they vary across cultures; (h) recognizing culturallydefined support networks as well as natural helpers; and (i) ensuring thefidelity of implementation in the face of such diversity. The report providesnumerous illustrations in each of these areas, drawing upon the existentliterature.

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Given this potentially important source of variation, one cannot helpbut wonder: How do significantly non-white samples distribute across pro-gram types and is this similar to their white counterparts? Do programeffects differ in terms of the ethnic and racial background of interventionparticipants? That is, what are the effect sizes for the samples (25.4%) com-prising essentially white populations as compared to those (26.5%) notedabove? Do mean effect sizes vary in any systematic way by ethnicity/raceamong outcome domains?

LEVEL OF INTERVENTION

Among the various comparative dimensions employed by Durlak andWells in their analyses, person- and environment-centered interventions arecarefully distinguished from one another in order to test the utility of thislong-held distinction in prevention programming. The results indicate thatthe distinction in general is meaningful. Moreover, with respect to the latter,there is strong evidence that effect sizes vary by type of setting. Specifically,the authors identified two basic contexts within such environment-centeredpreventive interventions have been mounted: school, ranging from a singleclassroom to an entire educational institution, and home, largely focused onparenting dynamics. Their analyses reveal that the school-based programsproduced significant effects, whereas the home-based programs did not.Thus, it is important to anticipate that preventive efforts will likely exhibitdifferential impacts across various settings.

In this vein, it is unfortunate that home and school are the only levelsof social complexity represented among the environment-centered interventionsreviewed by the authors. Such a limitation probably is a function of the adequacyof available outcome data and deadline for inclusion of published examples(e.g., 1991 or earlier), rather than oversight on the part of the authors. Yet, arapidly emerging emphasis on small group/organizational and community-basedapproaches to prevention programming has generated numerous interventionsat municipal, regional, national, and even international levels (Braithwaite &Lythcott, 1988; Fawcett, Paine, Francisco, & Wet, 1993; Hawkins & Catalano,1992; Weiss, 1991). Consider, for example, the Community Partnership DevelopmentProgram (Center for Substance Abuse Prevention, SAMHSA), the ColoradoHealthy Communities Initiative (The Colorado Trust), the Fighting Back andHealthy Nations Initiatives (The Robert Wood Johnson Foundation), the NewVisions Program (Annie E. Casey Foundation), Healthy Cities Indiana (IndianaUniversity, State of Indiana Public Health Association, The W. K Kellogg Founda-tion; Ftynn & Rider, 1991), Healthy Communities Initiative (National CMc Leagueand US. Public Health Service), the Kansas Initiative (Wesley Foundation; Fawcett

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et al., 1993), and even the World Health Organization's Healthy Cities Project(WHO, 1984, 1986,1988; Ashton, Grey, & Barnard, 1986). The interventionsembodied in these efforts employ a wide range of community mobilization anddevelopment strategies intended to recalibrate social attitudes toward variousbehaviors, to engineer critical changes in decision-making processes, and to extendresponsibility for as well as investment in subsequent outcomes.

The underlying technology for inducing change among these larger ele-ments of social structure has been well articulated. However, conceptualizingand operationalizing the measurement of appropriate outcomes has provenelusive; but there is discernible progress. Hopefully, future updates of thefindings presented here will have available to them sound empirical datathat can speak to the effectiveness of the many community-based preventiveinterventions underway in our neighborhoods, cities, and even states.

MENTAL HEALTH PROMOTIONAND ILLNESS PREVENTION

Durlak and Wells (1997) declare that "current findings suggest thatthe Institute of Medicine's (1994) decision to exclude health promotionas a preventive intervention is premature. Health promotion appears tohave value as a preventive intervention, although more data are needed"(p. 141). Such effects, albeit modest at this point, are encouraging. But,contrary to the authors' assertion, this is consistent with, even anticipatedby the IOM report: "In many respects, the goals of decreasing risk andincreasing protection in the disease-oriented model and goals of promot-ing mental health are not mutually exclusive, either in practice oroutcome" (p. 334; see also pp. 339-340). The IOM struggled to broadenthe field's appreciation of a large body of programs, the purpose of whichis to enhance individual or collective competence, self-esteem, or well-being without necessary reference to deficiencies, pathology, or disease.Chapter 9 went to great lengths to clarify the conceptual underpinningsto this orientation, to explicate a quite different set of motives and goalsthan those subsumed under the rubric of "intervention," and to illustratea wide range of possible approaches. Durlak and Wells are correct toinclude the preventive effects of mental health promotion efforts in theiranalyses. However, readers would be misled if, on the basis of this deci-sion, they concluded that the findings represent the sum of such efforts'effects. Perhaps one day, we will have the benefit of an equally powerfuland valuable review of the contribution of mental health promotion pro-gramming to those aspects of positive self-regard that stand apart fromdisease or disorder.

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Ashton, J., Grey, P., & Barnard, K. (1986). Healthy Cities: WHO's new public health initiative.Health Promotion, 1, 319-324.

Braithwaite, R. L., & Lythcott, N. (1988). Community empowerment as a strategy for healthpromotion for black and other minority populations. Journal of American MedicalAssociation, 261, 282-283.

Coie, J. D., Watt, N. F., West, S. G., Hawkins, J. D., Asarnow, J. R., Markman, H. J., Ramey,S. L., Shure, M. B., & Long, B. (1993). The science of prevention: A conceptualframework and some directions for a national research program. American Psychologist,48, 1013-1022.

Durlak, J. A., & Wells, A. M. (1997). Primary prevention mental health programs for childrenand adolescents: A meta-analytic review. American Journal of Community Psychology, 25,115-152.

Fawcett, S. B., Paine, A. L., Francisco, V. T., & Vilet, M. (1993). Promoting health throughcommunity development. In D. Glenwick & L. A. Jason (Eds.), Promoting health andmental health in children, youth, and families. New York: Springer.

Flynn, B., & Rider, M. S. (1991). Healthy Cities Indiana: Mainstreaming community healthin the United States. American Journal of Public Health, 81, 510-511.

Hawkins, J. D., & Catalano, R. F. (1992). Communities that care. San Francisco: Jossey-Bass.Institute of Medicine. (1994). Reducing risks for mental disorders: Frontiers for preventive

intervention research. Washington, DC: National Academy Press.Price, R. H., Cowen, E. L., Lorion, R. P., & Ramos-McKay, J. (1989). The search for effective

prevention programs: What we learned along the way. American Journal ofOrthopsychiatry, 59, 49-58.

Weiss, S. M. (1991). Health at work. In S. M. Weiss, J. E. Fielding, & A. Baum (Eds.),Perspectives in behavioral medicine: Health at work (pp. 1-10). Hillsdale: Erlbaum.

World Health Organization. (1984). Health promotion: A discussion document on the conceptand principles. Health Promotion, 1, 73-76.

World Health Organization. (1986). The Ottawa charter for health promotion. HealthPromotion, 1, ii-iv.

World Health Organization. (1988). WHO Healthy Cities Project: An update. Geneva,Switzerland: Author.

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