Designing Evidence-Based Public Health and Prevention Programs

Expert Program Developers Explain the Science and Art

Mark E. Feinberg, Mark E. Feinberg

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429534010
• Edition: 1
• Topic: Education
• Subtopic: Education General

Demonstrating that public health and prevention program development is as much art as science, this book brings together expert program developers to offer practical guidance and principles in developing effective behavior-change curricula.

Feinberg and the team of experienced contributors cover evidence-based programs addressing a range of physical, mental, and behavioral health problems, including ones targeting families, specific populations, and developmental stages. The contributors describe their own professional journeys and decisions in creating, refining, testing, and disseminating a range of programs and strategies. Readers will learn about selecting change-promoting targets based on existing research; developing and creating effective and engaging content; considering implementation and dissemination contexts in the development process; and revising, refining, expanding, abbreviating, and adapting a curriculum across multiple iterations.

Designing Evidence-Based Public Health and Prevention Programs is essential reading for prevention scientists, prevention practitioners, and program developers in community agencies. It also provides a unique resource for graduate students and postgraduates in family sciences, developmental psychology, clinical psychology, social work, education, nursing, public health, and counselling.

Chapter 1

Introduction

Mark E. Feinberg

Having completed training in theoretical, empirical, and clinical psychology, I set out into the world with a Ph.D. and a set of clinical skills that—hopefully—allowed me to help clients make positive changes toward better mental and behavioral health. Along with other new clinicians from counseling, social work, psychology, psychiatric, and other training programs, I had tried to develop better therapeutic skills such as listening, exploring emotions, reframing cognitions, supporting problem-solving, and enhancing behavioral control (along with case management skills such as case conceptualization, assessment, diagnosis, and treatment planning). But once I began working in the prevention and public health research world and developing new interventions, it became clear that my graduate training had not fostered skills for developing prevention and behavioral-change program curricula. And such skills were not anything I had sought out—in fact, until I began looking for my first job, I did not know that there was a field of prevention science in which program development was a key focus.

As I began developing a preventive intervention program for families, Family Foundations, I relied on my clinical skills and my theoretical understanding of behavior change principles in fleshing out actual program content. But a great deal of my curriculum development work was guided by my own personal experience and observation of others—what supports and catalysts had worked for me, what I had seen work for friends and family members in their journeys towards becoming mentally and emotionally healthy. Developing new program content, in that first project, and since then, began with brainstorming, and then proceeded largely guided by my intuition about what would work. More in the background than I want to admit, were empirically validated behavior change principles.

The subtitle of this book refers to the “art and science” of developing programs because, I believe, a great deal of the design of preventive and public health programs remains an art or craft. That is, whether we are trained clinicians or not, we bring our experience and understanding of how to facilitate positive, proactive change in ourselves, in other individuals, and perhaps in groups to bear in a creative process of developing new intervention models. As scientists, we base intervention development as much as possible on the current knowledge base of risk and protective factors, mediating mechanisms, target population characteristics, and behavior change principles. Yet the actual construction of a preventive public health program consists of an active leap beyond our knowledge base. Similarly, an architect’s design work is based on goals (how much floor space does a client desire, what loads must be supported, how many bathrooms are needed), informed by the knowledge of how different materials behave under different conditions. Yet the design of a new building emerges from a creative act that, while organizing building materials in ways that will facilitate the building requirements, is also concerned with shaping the experiences of people viewing or inside the building by creating an attractive, welcoming, stimulating, or comfortable environment. Although an architect’s prior experience designing buildings informs the approaches taken to help shape such intangible experiences, a synthesizing, intuitive, and creative factor continues to be critical in developing new buildings…or behavior change programs.

For program developers from the research world, defining the risk/protective mechanisms affecting the outcome of interest based on existing research is the easy part. What is more difficult is, first, identifying a circumscribed target for change that is a lynchpin in the bio-psycho-behavioral-social system that leads to a cascade of positive consequences. Even more difficult is developing a feel for what supports, behaviors, and change mechanisms might be able to be taught to or conveyed to people that they will internalize and use in their life when challenged by internal or external factors.

The prevention architect’s goal is to achieve the most good, for the most people, with the least amount of money and effort. Consequently, program content and approaches must work for people with a wide variety of attitudes, strengths, inclinations, experiences, and capacities.

A program developer then needs to develop a sense of what tools (thoughts, perspectives, or behaviors) might work to help modify targeted behaviors for the majority of people in the target population—and how to facilitate the learning, internalization, and deployment of those tools. Although much of this process depends on trial and error experimentation (e.g., piloting), developing an intuitive sense of what tools may work and how to convey them is invaluable.

The purpose of this volume is to convey the experiences of leading program developers focused on fostering mental, emotional, social, and behavioral health: How have they approached the craft and science of creating new prevention and public health programs? What factors and decisions were they addressing as they began their early work? What have they learned along the way? It is my hope that such accounts will convey a sense of the wide variety of approaches and trajectories that leading program developers have taken, responding to a felt need to address a range of concerns and issues across the prevention and public health spectrum. I hope these accounts will prove useful to students, trainees, interventionists, and researchers in developing the craft and science of program development.

In conceptualizing this volume, I was initially interested in the approaches taken by different program developers to the task of creating curriculum content. However, Matt Sanders suggested that my proposed focus was too narrow—that there are a range of processes and concerns that program developers must address beyond the development of behavior-change content itself. Agreeing with that, I widened the focus of the volume to include additional program factors that required attention and development, such as providing training, ensuring fidelity, managing intellectual property rights, the non-profit or business side of dissemination. Some authors focused on the task of content development, while others discussed a wider range of issues around program implementation, sustainability, and refinement. I believe that this mix reflects an interesting diversity of approaches, experiences, and interests of program developers that will be useful for those starting to develop their own programs.

I appreciate the contributions of all of the authors. Such sharing of experience and wisdom helps build a field, a body of knowledge, and the future strength and efficacy of future prevention programs. This also counters the tendency for academic incentives to halt collaboration. In academia, reputation, position, access to grant funding and so on is largely based on the quantity and quality of original, published work in peer-reviewed journals. To protect their intellectual capital, intervention developers sometimes shun collaboration, or collaborate only within their established team, limiting innovation and potential societal impact. Although maintaining boundaries around one’s work is healthy, the trick is finding a balance between overly restrictive boundaries that shut down further innovation and allowing one’s work to diffuse into the zeitgeist without careful testing and development.

A further pull away from collaboration and field-building is the lure of financial success if a program becomes valued and widely disseminated. I would venture that the economic value of effective and even cost-effective prevention and public health programs is rarely realized given the many challenges to the large-scale dissemination of evidence-based prevention and public health promotion programs. Financial issues can be complicated. An employee’s institution—whether a university or non-profit research organization—typically owns all of the intellectual property that employee develops at work. For example, I own a small business that licenses the intellectual property of a program I developed at Penn State from the university in order to disseminate it; the business pays a royalty to the university based on sales of the program. But situations differ. I know of colleagues whose institutions declined to claim the intellectual property and instead gave ownership to the program developer because the program seemed to be of limited financial value compared to the costs of developing contracts and monitoring the IP.

For some—perhaps most—program developers I have talked with, starting and managing a small business in order to disseminate a program is a headache. Most researchers in our fields are not business oriented; we are not experts at, nor do we enjoy business activities.

A number of chapters in this volume discuss some of the challenges associated with dissemination, going towards scale, maintaining fidelity, and developing scalable infrastructure. Some programs in this volume—including the Incredible Years, Keepin’ it Real, GenerationPMTO, Triple P, the Nurse-Family Partnership, Strengthening Families Program 10–14, Team Resilience and others—have had significant dissemination success. In some cases, this success has been due to a strategy for scaling up that program developers adopted early on and pursued with some degree of effort and devotion of resources. Other programs grew more slowly and organically, as awareness of the program’s benefits spread among communities and decision-makers. The dissemination of other programs benefited from a large-scale government-funded initiative; and still others were fortunate to form a partnership with a national non-profit organization interested in promoting the program.

Some chapters in this volume describe programs that have developed a strong evidence base and are engaged in dissemination strategies that include translating the program for other populations and delivery modalities; for example, New Beginnings Program, the Anger Coping and Coping Power programs, and Familias Unidas have moved towards the development of web-based programming and delivery. Still other chapters in this volume describe programs that have only recently developed evidence and have not yet turned the corner towards achieving wider dissemination—Cod-Cod, SIBS, Recipe4Success. Accordingly, these chapters have a relatively greater focus on the nuts and bolts of content creation and refinement.

In the 18th and 19th centuries, public health pioneers were centrally concerned with reducing the transmission of infectious disease—as we are again today, as I write this in the early stages of the COVID-19 pandemic. The early public health pioneers veered away from older ideas about religious and moral causes of disease, and worked from a rudimentary understanding of disease focused on filth as a cause and transmission vector of disease. Public health efforts such as quarantine and isolation had often been initiated in response to intermittent epidemics; but in the “great sanitary awakening” of the 19th century, public health initiatives became proactive. Ongoing public health campaigns aimed to prevent disease outbreak through, for example, enhanced personal hygiene.

Early sanitary efforts were carried out on two levels: First, reformers encouraged changes to the urban built environment, such as incorporating channels and then sewers into street plans to carry human waste and refuse away from living areas. The goal was to reduce the “foul air” that was thought to convey and transmit disease. Second, reformers encouraged changes in individual behavior, such as hand washing. These two levels of work, the community and the individual, continue to define the basic approaches to public health and prevention today. The work described in this book is largely in the tradition of focusing on encouraging change at the individual level.

As descendants of the early public health and prevention advocates, we are likely addressing similar issues as they did as we design the interventions of the 21st century. What are the key behaviors to target to promote greater health and less suffering? How to frame a program’s approach so that participants can see how the program is consonant with their own deeply held values and are motivated by an alignment of goals? How to sustain change? How to sustain the organizations and activities that create and sustain change?

As the public health and prevention fields have grown, impelled in part by a seemingly growing number of inter-related mental, behavioral, and physical health problems, opportunities for contributing to these fields have expanded. In addition to developing programs and conducting efficacy research, areas of work now include cultural adaptation and tailoring, methodological innovation, implementation science, cost-benefit analysis, and community-based participation. Each of these areas has become a field unto itself. As with the rest of science, public health and prevention science has increasingly become a team sport.

As I mentioned above, the pathway from initial program development to widespread scale up differs greatly across programs. Across these different trajectories, however, one common element among all of the programs in this volume is that the developers invested considerable time into establishing a rigorous research base validating the program’s benefits. The science of replication has taught us that initial positive experimental results are often not replicated. Thus, dissemination has tended to await additional confirmatory trials, delaying dissemination over several years. Although this process can be painfully slow, it is the existence of a rigorous evidence base that has played a key role in the decisions by local schools or agencies, funders, and national policy-makers to invest in some of the programs described in this volume.

Unfortunately, new opportunities for our work seem to arise regularly. I have seen the emergence—or at least a new level of public recognition—of the importance of several new health problems over the past 20 years: new addictive substances such as prescription opioids, obesity, youth suicide, loneliness. As new social and health problems arise, some innovators move quickly to fill a gap and market programs or strategies that purport to address the new problem. For those of us committed to an evidence-based approach, these rapid responses may evoke a sense of jealousy, competition, or impatience in us at times. However, while others may more quickly gain attention and offer solutions, the slower path of piloting, efficacy testing, and effectiveness research leads to greater health benefits in the end. While there are important efforts to make our development and testing processes quicker, more nimble, and responsive, the need for careful assessment and replication cannot be bypassed.

For my own part, I have experienced impatience and jealousy at times when others achieve success with a program that has a limited or no evidence base. The advice I received from my primary mentor in prevention science, founding director of the Edna Bennett Prevention Research Center at Penn State, Mark Greenberg, has been helpful. Having developed PATHS, a leading social-emotional school-based program, Mark counseled me to keep my focus on doing good science. Pursuing high-quality, rigorous science in the interest of improving human wellbeing has been the core value of our center; and that is what, in the end, will prove most valuable. Over the years, I have developed a great appreciation for the lasting importance of our work when we do good science. Even if the programs I have developed or co-developed do not go to scale, I am content with having worked with other colleagues to illuminate how a new approach or strategy has potential to prevent and reduce suffering. Hopefully another developer will follow up on our work and move beyond it, achieving widespread dissemination after resolving the acceptability, implementation, or dissemination obstacles we have encountered.

In that vein, I hope this volume contributes to your own journey in integrating the art and science of developing public health and prevention programs. I encourage you to learn from the skills, perspectives, and advice offered here, and then develop even more effective and sophisticated ways of supporting health and well-being. Please then share your wisdom and knowledge with those who follow your lead, and help prepare them to contend with the new health and social problems that arise in their generation.

Mark Feinberg

Topanga, California

Part I

Child and Adolescent

Chapter 2

Cognitive-Behavioral Intervention for Aggressive Children

The Anger Coping and Coping Power Programs

John E. Lochman, Caroline L. Boxmeyer, Ansley T. Gilpin, and Nicole P. Powell

Starting Point

John Lochman’s initial interest in working with children with behavioral problems started in his graduate school years at the University of Connecticut. His fellow graduate students and he were inspired by the prevailing enthusiasm for research-based behavior therapy interventions, and by emerging notions about community psychology, which emphasized how their knowledge of interventions could be taken into real-world community settings such as schools. These interests led two of the faculty, George Allen and Jack Chinsky, and two other graduate students, Howie Selinger and Steve Larcen, along with John, to implement an integrated, multilevel prevention approach in one school. His portion, considered to be tertiary prevention, involved a test of behavior-modification training that was delivered to teachers to use with their m...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• 1 Introduction
• PART I Child and Adolescent
• PART II Parenting
• PART III Family
• PART IV Family Transitions
• PART V Adult
• Index