• By Kevin Mount
  • Posted on Thursday 21st May, 2009

A taste of the confusion of prevention in the raw

Take the DVD wrapper and the handbook graphics at face value and you might imagine that prevention programs belong only in the studio world of The Truman Show, where everything is foil-wrapped: neighborhoods, facilities, people, problems.So it was reassuring for the posse of West Coast study tourists to be reminded that once out of the box most prevention programs are delivered by ordinary people, in ordinary settings, with ordinary resources.For example, we heard about programs being implemented in a farming community with a population of 5,000, mostly Hispanic, where 80% of the children were receiving free or reduced-price school lunches. At the other extreme, programs were operating in a Seattle suburb where most families had two working professional parents and the median family income was almost $18,000 higher than the city average.In the middle-class Seattle suburb, we were told, parents were only too eager to join up, "to become even more perfect parents". In the rural community, at least at the outset, nobody wanted to know. Academics were treated with suspicion, and the legacy of failed prevention efforts aggravated already low levels of trust in authorities. And neither community had a critical mass of staff well-trained in the concepts or practice of prevention science. We saw some of the realities for ourselves – in the windowless basement of a hospital and in a clinic for Methadone users, for example. When parents play the role of deviant friendsAnd we met some of the real delivery people. Some were trained in social work, others in therapy or community work. Some were full-time; for others it was one job among many.As for what happened in the sessions, it was often surprisingly – perhaps deceptively – simple. In a Guiding Good Choices workshop, a group of children watched videos of young people who were good or bad at resisting peer pressure. Then they rehearsed a five-step refusal routine in which their own parents played the role of deviant friends. In the Methadone clinic, a therapist used Families Facing the Future routines to lead a discussion with parents whose drug abuse had caused their children to be removed from them.The project in the Seattle suburb was at pains to contact parents weekly to remind them about what to bring to sessions and to offer incentives such as free membership at a local leisure facility. In the rural community, care was taken not to step on people's toes, for instance when seeking to introduce a program in a school that was already doing something similar, albeit not evidence-based.In both neighborhoods a coalition of professionals and local residents decided what problem to focus on and what programs to implement: "It wasn't just two people in a room," was how one coordinator put it. In both cases these community-based efforts paid off in terms of high participation rates. In the rural county a connection with a public health clinic which employed a large number of Latinos proved helpful. Parents who misuse drugs are generally hard to engage, but participation in the Families Facing the Future program was sustained.The flip side of high participation is that a proportion of families who do not need a program will get it. In the case of Guiding Good Choices, there is a public health counter-argument that only by reaching a significant proportion of families will it be possible to change social norms.That said, prevention programming can have unanticipated consequences. The Seattle suburb coalition, in addition to selecting proven programs, introduced a Drug Free Homes Parent Pledge. There is no evidence that pledge signing works, but perhaps it is a price worth paying for being able to tap community energy.Schools in the same community initially resisted introducing LifeSkills Training, because teachers were concerned that time spent teaching social skills would leave less time for “proper subjects” such as Math and English.And, with the best will in the world, some things will go wrong. In one instance the coordinator stepped back to enable others to deliver programs – with disastrous consequences. "The monitoring forms were saying that the tutors did not appear prepared or genuinely interested in teaching," she told us. "One flash point was when a tutor who did not have children used the example of teaching her dog to communicate a parenting skill."Delivering prevention programs well takes time. One county described by the Washington State team had moved from no programs to three in four years. It was to be regarded as a success story.Observing prevention in action can be slightly dispiriting at times. Smart programs, so well researched and packaged, and this is what they look like in the raw? But that's the point. However simple or messy the real world, the best programs will match up to the ground conditions – and they work.Nick Axford[See also: Louise Morpeth's blog about Families Facing the Future with videos of facilitators and participants]

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