What kinds of prevention are there?


There are three ways to categorize prevention strategies: according to effectiveness, according to how they’re intended to help (their methodology), and according to whom they’re intended to help (their audience/clientele).  Let’s take a look at all three classification systems.


Classification by Effectiveness

The first (and most recently developed) way to classify prevention strategies is by whether they’ve been proven effective.  Strategies that have been so proven are called evidence-based practices, or EBPs.  For referral to lists of EBPs, see our Resources page.  Other strategies are either unproven or disproven.

Though this classification system is the newest of the three (It’s only been in the last decade or so that preventionists have realized effectiveness cannot be assumed), the label “EBP” is fast becoming one of the most influential factors in the strategy selection process.  A strategy may be effective, but if it’s under-researched, funders are less likely to approve it.  This selectivity is a double-edged sword in that it ensures the effective application of resources, but it dampens innovation.


Classification by Methodology

The second classification system, classification by methodology, divides all prevention strategies into two groups: individual or environmental.  Both types ultimately hope to change individuals’ behavior; however, the means by which they attempt to change behavior are slightly different.  Whereas individual prevention strategies try to change people’s behavior by changing their minds, environmental prevention strategies try to change people’s behavior by changing their environment.

To illustrate the difference between individual and environmental prevention, consider this situation.  Suppose a community is experiencing high rates of car crashes related to underage drinking.  The community can respond in numerous ways.  It can educate its students about the dangers of drinking and driving: it can enrolling them in an online curriculum like AlcoholEdu or a classroom curriculum like DARE.  It can engage students’ emotions by hosting a recovering alcoholic as a speaker or by dramatizing a car crash at an assembly.  It can also increase enforcement of alcoholic beverage laws by increasing the number of compliance checks at alcohol retailers, patrol cars on the streets, and penalties for social hosting.  Some of these strategies are individual, and some are environmental.

AlcoholEdu, DARE, a speaker, or a mock car crash are all individual strategies: they attempt to change students’ thoughts and feelings about DUI.  The enforcement efforts are environmental strategies in that they don’t attempt to change anyone’s thoughts or feelings about DUI so much as counterbalance them with their existing thoughts and feelings about the need to avoid being fined or arrested.

Currently environmental prevention strategies are dominating the world of prevention since they are generally more economical.


Classification by Audience/Clientele

The last classification system mentioned above is by audience or clientele.  According to this classification system, there are three types of prevention: universal, selected (targeted), or indicated.

Universal prevention is for everyone.  It’s the type of prevention people need regardless of whether they’re healthy or sick, well or unwell, not at risk or at very high risk.  An example would be a smoke-free area: it prevents everyone, smokers and non-, from inhaling toxic chemicals that negatively affect their health.

Selective prevention is for people who are at risk of experiencing a particular problem.  (For a cogent discussion of risk and protective factors, see SAMHSA’s “Prevention and Behavioral Health” tutorial.)  An example of selective prevention would be Head Start, “a federal program that promotes the school readiness of children ages birth to five from low-income families.” (1)  This program recognizes that being in poverty increases a child’s risk of failing to obtain a good education.

Last but not least there’s indicated prevention.  Indicated prevention is for individuals who have shown signs of a problem but who have not yet been diagnosed with it.  An example might include the screening of a student who has been found in possession of illicit drugs.

Sometime identifying whether a prevention strategy is universal, selective, or indicated can be challenging.  The confusion here usually results from the fact that, when it comes to universal strategies, “everyone” doesn’t always mean “everyone in the entire world” or “everyone in the entire community.”  Sometimes it means “everyone to whom it applies.”  A better explanation might include, “everyone to whom it applies, regardless of whether they’re at risk of the problem we’re trying to prevent.”  To elucidate this discussion, take a look at the chart and accompanying discussion below.

Strategy              
Universal
Selective
 Indicated
 Explanation                                              
1. Suport groups for adults with a history of mental illness   X   Those who attend the support groups have a risk factor for mental illness (i.e., a family history of it), but the strategy description does not mention their having shown signs of mental illness.  Were they to show signs of mental illness, this strategy would be indicated.
2. Laws that increase penalties for providing alcohol to minors  X      Laws apply to everyone in a community, regardless of how likely (at risk) they are to provide alochol to minors.
3. Programs for families experiencing transitions    X    Families who participate in the program have a risk factor for many behavioral health problems (i.e., the fact that they are in transition), but the strategy description does not mention their having signs of any behavioral health problem.  Were they to show signs of a behavioral health problem, this strategy would be indicated.
4. Social norming campaign to decrease norms favorable to marijuana use X     The strategy description does not mention what type of campaign this is; therefore, we must assume it is designed for a general audience.  A general audience includes people who have risk factors in their lives that put them at risk of using marijuana as well as people who do not have these risk factors in their lives.  Since this strategy reaches both groups, it is universal.  Were the strategy designed to be seen by or to appeal to a certain group with a risk factor increasing likelihood of using marijuana (children whose parents approve of marijuana use, for instance), then it would be a selective strategy.
5.  Strengthening programs for families in poverty   X   Families who participate in these programs are in poverty.  Poverty is a known risk factor for multiple behavioral health problems.
6. Mentoring programs for children of incarcerated parents   X   Children who participate in the mentoring programs have an incarcerated parent, which is a risk factor itself and suggests other risk factors as well.
7. A referral process for older adults identifed with prescription drug problems     X The older adults who benefit from the referral process have been identified as showing signs of prescription drug problems.  They have moved beyond being at risk for prescription drug abuse; they have actually experienced it.  Had they only shown risk factors (suffering from chronic pain, for instance), this strategy would be selective.
8. Prevention programs for all middle school students in a community X     This strategy does not apply to all people, but it does apply to all people in middle school, regardless of their level of risk.  A middle school population includes students whose lives contain many risk factors for behavioral problems and students whose lives contain none (assuming that being a middle schooler is not itself a risk factor.  Were it, this strategy would be selective.).
9. College campus policies on alcohol X     The strategy description does not mention for whom the policies apply; therefore, we must assume the policies apply to the entire campus population.  A campus population includes people whose lives contain risk factors for alcohol abuse and people whose lives contain none.  Were these policies only to apply to an at-risk sub-population, then this strategy would be selective.  Were they only to apply to a sub-population that had abused alcohol, this strategy would be indicated.
10. Programs for people arrested for drunk driving     X People arrested for drunk driving have already abused alcohol.  They have manifested that they have an alcohol problem (not necessary a dependence or addiction, but a problem nonetheless)

Source: "Substance Abuse Prevention Skills Training: A Behavioral Health Workforce Development Curriculum," Center for the Application of Prevention Technologies, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Administration


Classification Overlap


The fact that there are multiple ways of understanding and categorizing prevention strategies means that any given strategy can be described three different ways and designated with three different labels. The chart below gives several examples.  It lists ten strategies for reducing underage drinking and describes them according to each classification system.

Strategy                                          
Classification by Effectiveness     
Classification by Methodology        Classification by Audience/Clientele
 1. Have an alcohol-related motivational speaker offer personal testimpny to high school students at a school-wide assembly.  Disproven Individual Universal
 2. Host a Reality Tour, a three-hour educational program hosted in a community setting for parents and children ages 10-17.  EBP Individual & environmental Universal
3. Require high school English teachers to present a traditional lecture on substances and consequences. Unproven Individual Universal
4. Require high school English teachers to administer AlcoholEdu, an online interactive alcohol education and prevention course designed to increase alcohol-related knowledge, discourage acceptance of underage drinking, and prevent or decrease alcohol use and its related negative consequence. EBP Individual & environmental Universal
5. Send those convicted of underage drinking to boot camp. Disproven Individual Indicated
6. Conduct Responsible Beverage Servive and Sales Training for alcohol retailers. EBP Environmental Universal
7. Reduce alcohol outlet density through zoning restrictions. EBP Environmental Universal
8. Implement Brief Alcohol Screening and Intervention for College Students, a prevention program for college students who drink alcohol heavily and have experienced or are at risk for alcohol-related problems. EBP Individual Selective & indicated
9. Increase the number of sobriety checkpoints. EBP Environmental Universal
10. Increase the penalties for those convicted of sale to underage persons, social hosting, underage possession or consumption, and driving under the influence. EBP Environmental Universal

Sources:
a. National Registry of Evidence-Based Prevention Practices
b. "ODMHSAS Evidence Based Strategies Matrices," Oklahoma Department of Mental Health and Substance Abuse Services
c. "Don't Do It!  Ineffective Prevention Strategies," The Colorado Department of Education

 


1. http://eclkc.ohs.acf.hhs.gov/hslc/hs/about