The Promise of Prevention

Abstract: Prevention of social ills benefits individuals and society. Yet it can be difficult to make the case that a program or policy kept something from happening. However, research around prevention can be done, and the field is on the rise. Some studies examine interventions that already exist and use research methodologies to determine if they have been effective. For example, SSA’s Neil Guterman is looking at Parent Aid Services and Sydney Hans is looking at the Doula Home Visiting Initiative. Other researchers use evidence-based findings to create intervention programs from the ground up: Alida Bouris is researching how parents of Latino adolescent gay and bisexual males can be support to prevent HIV infection among their children and Jennifer Bellamy is researching how to help young, first-time fathers become involved positively with raising their children.

Research on how to prevent social ills is on an upward trajectory—and that's fueling a wide array of policies and programs

Published in the Fall 2010 issue of SSA Magazine

Since its inception, social work has been interested in not only serving those in dire circumstances, but also in getting ahead of the problems that services aim to address. Keeping the crime from being committed, the substance user away from dependence, the child safe from harm or the student in school is a step better than attempting to rebuild lives scarred by jail, addiction, maltreatment or a failed education. Aid to those who are troubled will always be necessary, of course, but how wonderful it would be for an individual to never face that trouble in the first place.

In many ways, social work is a natural field to advance the promise of prevention. "Social workers think about the macro level and about people in the environment," says Sydney Hans, SSA's Samuel Deutsch Professor. "In clinical practice we're working in schools, in youth centers, in the community. We see that supporting youth development is cheaper than prison—and we see the effects of prison on that youth's life and his family."

For most of social work's 100-plus year history, however, investment in prevention has been difficult to bring to scale. "Policymakers could just say, 'That sounds nice, but where's the hard evidence?' It used to be difficult to show that prevention works. Social work professionals could themselves see the benefits of prevention, but they had a hard time 'proving it,' to the public," says Neil Guterman, the dean of SSA and the School's Mose and Sylvia firestone Professor. "How do you show a program works if its aim is to keep something from ever happening? It seems almost paradoxical."

Yet research has been leaping over that apparent paradox for years. For example, from health care research, we now have scientific proof of the impact of smoking, obesity, nutrition and other factors on everything from heart disease to depression. Prevention research is why your doctor may tell you to watch your cholesterol or give you a vaccination at your annual check-up, and why there's fluoride in your drinking water.

Attention to prevention in social and health care services is unmistakably on the rise. Just look at the 2010 health care reform bill, the Patient Protection and Affordable Care Act, which creates the national Prevention, Health Promotion and Public Health Council, provides grants to small employers to create wellness programs, mandates the disclosure of nutrition content in chain restaurants, and requires insurers to cover key evidence-based clinical preventive services.

"There are a lot of prevention policies in this bill," says Harold Pollack, the Helen Ross Professor at SSA. "That's noteworthy. It's hard to get, say $10,000 to build a fence around a local well. But when a toddler falls in and the rescue attempts are on cable TV for three days, then we're willing to spend $100,000 to save her. We're starting to understand now that the life you save with the fence is as real as the toddler who's already in peril. And in public health policy, we are now creating financing structures and regulations to ensure that prevention receives higher priority."

Much of this is thanks to the rise of research that offers proof positive that programs and policies do indeed reduce major social problems before they have a chance to erupt—and save the public money at the same time. For example, a groundbreaking study of a home visitation program to young parents who are at-risk of child maltreatment in the mid-1970s showed that nearly 80 percent of mothers in the program had fewer verified reports of abuse or neglect and more than 50 percent fewer of the children avoided arrest as adolescents. A slew of studies of similar programs around early childhood development have shown the same kind of results.

Today, supporting newborns and toddlers and their families is a leading prevention policy priority. It's been a top agenda item for the Obama administration—for example, the health care bill includes $1.5 billion allocated to home visitation programs. University of Chicago Nobel laureate James Heckman, the Henry Schultz Distinguished Service Professor in economics in the College and the Harris School of Public Policy, is a researcher and outspoken advocate on why early prevention and support are effective and makes good economic sense. A recent study by the RAND Corporation reported that every dollar spent on home visitation saved $5.70 in other governmental, health care and social costs. And even the U.S. Chamber of Commerce is on board, recently publishing a report "Why Business Should Support Early Childhood education" through its institute for a Competitive Workforce.

"There's been a historic shift in social welfare scholarship around prevention in the last 10 or 20 years, an unmistakable growth of research that sheds new light on ways to both prevent social problems and reduce public expenditures, and of connecting this research to local, state and federal policy," Guterman says. "And this growth continues in an upward trajectory."

Advocates for early childhood development may be the most obvious proponents of prevention policies, but look almost anywhere in social services and you'll see a similar story. for example, SSA Professor Mark Courtney has testified to a Congressional committee about his research on the collateral benefits of providing support to foster children after age 18, which helped the passage of the fostering Connections to Success Act in 2008. Dexter Voisin, an associate professor at SSA, influenced policy related to framing public health messages in Illinois with his studies of how to best get HIV prevention messages to youth. "Policymakers shouldn't make decisions just based on anecdotal stories," Voisin says. "They need to look for hard data and know that what they're doing works or will have the potential to work."

Social welfare scholars are increasingly turning to the latest research techniques that enable reporting with confidence that a program or policy will have a specific preventive impact. Randomized clinical trials, like those used to test out new medications, allow researchers to scientifically weigh the efficacy of delivering a specific service to vulnerable individuals, when compared against a group who hasn't received the service. And longitudinal studies give correlational information that can help identify the early causes of social problems, long before they crop up.

"Increasingly, social welfare scholars are relying on such statistical strategies as 'propensity score matching,' which permits us to construct a statistically unbiased control group, when we can't feasibly carry out a randomized clinical trial in the real world. Others are turning to techniques such as 'structural equation modeling', which enables us to much better estimate causal precursors to social problems than before," Guterman says. "The use of these strategies is growing because the research methodologies have really advanced, and social welfare scholars are increasingly recognizing their power."

One of Guterman's current projects is a four-year randomized trial of the impact of parent aide services, a paraprofessional home-visitation program for parents identified as at high risk of child maltreatment. A historical predecessor to home visiting programs, parent aide services have been operating in hundreds of communities across the United States for several decades, but there has never been a controlled evaluation determining whether they work or not. His study, currently being prepared for publication, finds that parent aide services have a statistically significant positive impact after six months in reducing parental stress, maternal depression and anxiety, and reducing psychological aggression and physical assault toward a child.

Hans is in the midst of a similar research project for the Doula home visiting initiative, which has been operating for more than 20 years, and has served more than 10,000 families since inception. "Nobody has really ever studied it to determine if it's having the effects as planned," Hans says. "For the Ounce of Prevention [the agency that operates the program], this is an opportunity to show policymakers that research backs up that there are useful results and a cost benefit."

Deborah Gorman-Smith, a research fellow at Chapin Hall specializing in prevention of youth violence and president-elect of the Society for Prevention research, a 20-year-old multidisciplinary organization, points out that with a growing wave of prevention research, we're learning more about longstanding programs. Sometimes the results are heartening, giving a boost to advocates for ongoing support, and sometimes what was considered successful is found to fall short.

Perhaps the most infamous example is DARE, the national anti-drug use program that has been implemented across the country at a cost of millions of dollars over many years. "Research found that not only was it not having a positive effect in preventing substance abuse, for some groups of youth it was having a negative effect," Gorman-Smith says. Even proof that a prevention program isn't working is useful, though, since the information can help free up resources for better alternatives.

"The field has become more methodologically sophisticated, while at the same time recognizing that much can be learned about the long term impacts of programs by taking advantage of existing administrative or archival data," Gorman-Smith says.

Gorman-Smith is also the principal investigator and director of the Chicago Center for Youth Violence Prevention, a new collaboration between Chapin Hall, the University of Chicago Crime Lab and the Chicago Project on Violence Prevention at the UIC School of Public health, which is the umbrella group for Ceasefire. The center, one of four national Academic Centers of Excellence funded by the Centers for Disease Control and Prevention, will build on earlier research to develop an integrated set of activities aimed at reducing youth violence within targeted Chicago communities, and use the knowledge gained in this process to inform violence-prevention efforts more broadly.

"We're appreciative of the opportunity to work with the center, which brings complimentary strengths and resources," says Roseanna Ander, the executive director of the Crime Lab. "That's important to our goal: We're interested in building a kind of portfolio of different kinds of interventions that work across the lifespan and for different populations, that have been tested and found to work."

The Crime Lab is currently running a randomized clinical trial of the Becoming a man— Sports edition (BAM) intervention, which helps low-income urban youth strengthen emotional self-regulation and social skills. "In many cases, young men get into violent situations because they have what's called 'hostile cultivation bias,' which means they have a tendency to view people as having more hostile intentions in ambiguous situations than is actually the case," explains Pollack, who, along with SSA Professor Jens Ludwig, co-directs the Crime Lab. "By strengthening socio-emotional skills, we can help youth avoid getting into a bad situation in the first place."

One of the fascinating aspects of prevention work is how one strategy can potentially lead to a cascade of multiple positive outcomes. By avoiding the criminal justice system, a young man who has gone through BAM can remain in school and stay on a much better track for future employment. With improved socio emotional skills he may lower the amount of stress in his life, which can impact mental health and substance abuse issues, and he may do better in school because he can avoid confrontations with teachers in the classroom.

Measuring all of these outcomes is currently beyond the scope of most studies, although the Crime Lab's research of BAM does include an assessment of the basic academic success of participants. "This is one place where the University of Chicago has a real advantage to gather this wide set of data because of our relationships with Chicago Public Schools, the Illinois State Police and on-campus organizations like Chapin Hall," Pollack says.

The work of Jennifer Bellamy, an assistant professor at SSA, is focused on how to help young first-time fathers become more positively involved with raising vulnerable children in order to prevent child maltreatment. Even though Bellamy's research won't explicitly measure all the ways the program helps secure a better life for the children, the existing body of research can build a case for the program's potential range of positive long-term impacts. For example, the National Institute of Mental Health is interested in preventing abuse and neglect because research has shown that child maltreatment is a factor across the lifespan for a wide variety of mental and physical health outcomes, and the National Science Foundation is interested in the issue because of documented links between violence prevention and educational outcomes.

Bellamy's research is also an example of where prevention research is heading—closer inspection of how to influence specific sub-populations. "There has been research about a number of programs that support young mothers, but not as much for young fathers," she says. "I'm looking at what would have that impact for a 16-year-old father—what are the needs, what will get him involved, what will help him parent."

Alida Bouris, an assistant professor at SSA, is also focusing on a specific population for her research: How the parents of Latino adolescent gay and bisexual males can be supported to help prevent HIV infection among their children. "Research shows that parents can have an important influence on their child's sexual decision-making and behaviors," she says. "But the majority of this research has focused on heterosexual youth. Historically, there's been an assumption that parents don't matter for LGBT youth, or that they only matter in negative ways. However, research is starting to show that parents can be an important source of support for LGBT young people and that they want assistance. At the same time, there isn't a lot of evidence-based guidance for parents and practitioners to draw upon, and most of the research has been conducted with white families."

Like Bellamy, Bouris is developing an intervention that can be evaluated in the context of a randomized controlled trial. Rather than finding an existing social service program and applying research methodologies to determine if it's been effective—as Guterman is doing with Parent Aide Services and Hans is with the Doula Home Visiting Initiative—researchers who are doing this kind of "social R&D" are using evidence-based findings to create intervention programs from the ground up, from identifying the best methods to recruit and retain participants to determining the kinds of services offered.

"Increasingly, prevention researchers are also the innovators themselves. Researchers can use scientific methods to guide the development of a novel strategy as well as to evaluate it," says Guterman, who has used this approach to design and test a program that provides peer support among young mothers to help prevent child maltreatment.

In 50 years, Stanley McCracken likes to tell his students, we may look back at this era and find it barbaric that an individual would even have an episode of severe mental illness—that early screening and prevention methods may have progressed to the point that mental health service is an entirely different profession. McCracken, a senior lecturer at SSA, also points out, however, that the field of mental health is far behind substance abuse in applicable prevention research. "In some ways, prevention has been the holy grail in mental health. Just now a pre-clinical level of psychotic disorder is being proposed for the DSM-V [the Diagnostic and Statistical Manual of Mental Disorders]," McCracken says. "And the path to realize real prevention in mental health is filled with tough ethical questions: What level of false positives are you willing to live with in identifying people who are at risk of mental illness and given a treatment? Is there a preventive intervention available with an acceptable risk/benefit profile? If you identify people early in life as susceptible for mental illness, would that end up stigmatizing them?"

And even if fields where prevention research is well-established, funding remains hard to come by, and there are real-world issues about how to bring a program that has been successful in one context to scale. Bouris points out that the rates of smoking have dropped dramatically in this country over the last 30 years, but it took a combination of policies, programs and approaches to accomplish that change—health education for children and adolescents, policy changes such as higher taxes on tobacco products and restricted access to cigarettes, public health campaigns and more.

"Behavior change is a complex endeavor," she says. "There's not necessarily a magic bullet—but each intervention, especially when it's evidence-based and targets multiple systems, can have an important impact." 

--by Carl Vogel