Presentation to the California Prevention Collaborative Summit

1. Presentation to the California Prevention Collaborative Summit The IOM Model and its Implications for Prevention Planning Presented by Joël L. Phillips Center for Applied Research Solutions (CARS) & Community Prevention Institute (CPI) April 25, 2006

2. Purpose of the Workshop • Introduce a historical perspective on the development of the IOM model. • Understand the components of the IOM model dealing with prevention (Universal, Selected, Indicated) • Examine each of the three IOM prevention components and how they can be used in planning prevention in your community.

3. Prevention:New Directions in Definitions Prevent: “Keep something from happening” However, different notions about what that something is: • First Incidence (Use) • Relapse • Harm (Consequences) • Risk Condition Itself

4. Prevention:New Directions in Definitions • Prevention rooted in public health field. (100 years) • Concern stopping infectious diseases. • Codified in 1957 – “Commission on Chronic Illness.” • Introduced the terms: • Primary • Secondary • Tertiary

5. Definitions • Primary Prevention: • Reduce incidence of a disorder (occurrence of new cases) • Secondary Prevention: • Reduce prevalence (that is total number of new and old cases) • Tertiary Prevention: • Reduce the Sequelae and complications arising from the problem/disorder once it is manifest.

6. The Traditional “Public Health” Model What is the nature/typical history of the behavior? Situations Linked to Health Consequences Early Manifestation of the Behavior/ Condition Outcome: Total Manifestation of Behavior/ Condition Critical Point 2 Critical Point 3 Critical Point 1 Secondary Prevention (Intervention) Tertiary Prevention (Treatment) Primary Prevention (Prevention)

7. Assumptions with this Model • Causal pathways can be identified. • Identify specific agents/vectors of disease. • However, not so easy in behavioral/ social science. • Early manifestations the problem/ condition itself is actually preventable. • However, not so easy to demonstrate.

8. Problems with the Model • Health/Disease Focus • Research demonstrates complexity of the association between risk factors and health outcomes. • Biological, psychological, social biophysical factors • Knowledge about the actual intervening mechanism still not completely known.

9. This model with its origin in medical science & linear assumption of causality is less relevant for those working in non-medical settings Conclusion

10. Development of Universal/Selected/ Indicated Approach for the AOD Field Three Steps in the Process First: R. Gordon. 1982, 1987 – presented model considering prevention by populationand risk. Used the Terms: • Universal • Selected • Indicated Focus: Still on Health Consequences

11. Development of Universal/Selected/ Indicated Approach for the AOD Field Second: Institute of Medicine (IOM). In a major publication in 1994, (“Reducing the Risk for Mental Disorder: Frontiers for Prevention Intervention Research” Patrick Mrazek and Robert Haggerty (eds). Presented the full Continuum of Care Model: Focus: Mental Health

12. Development of Universal/Selected/ Indicated Approach for the AOD Field Third: Approximately 2000, CSAP adopts language – mandates use by states (2003) Focus: Substance Use/Abuse

13. IOM Approach Assumes • The possibility to ‘prevent’ the occurrence of a health consequence – and that this can occur anytime. • Before ‘onset’ of the behavior/condition ‘during’ and with an individual experiencing the ‘full effect’ of the behavior/condition. • Different strategies and approaches to ‘prevention’ will be needed – depending where in the continuum you want to address the behavior/condition.

14. The Continuum of Care Protractor Different levels of prevention are distinguished by the level of risk of disorder/distress in various populations groups targeted.

15. Definition of IOM Prevention Components Universal Prevention Measures: • Address the entire population. • Aim is prevent/delay use of AOTD. Deter onset by providing individuals with information/skills Selected Prevention Measures: • Targets subsets of the population considered at risk by virtue of their membership in a particular segment of the population. • Key selected Prevention targets the entire subgroup regardless of the degree of risk of any individuals in the group. Indicated Prevention Measures: • Targets individuals who are exhibiting early signs or consequences of AOD use.

16. Merging ‘old’ definition of Prevention with IOM Approach Universal Average Risk Status of Population Average Need for Prevention Selected Increased risk status as a function of group/class risk – Increased need for prevention Target Condition Behavioral Manifestation Implications for Intervention Complications Direct, Indirect Efforts Implications for Treatment Indicated High risk status or a function of individual risk factors - High need for prevention Secondary Prevention To reduce existing cases (Prevalence) Tertiary Prevention To reduce complications (Treatment) Primary Prevention To reduce new cases (Incidence)

17. Some thoughts about IOM • Advantages: • Breaks from a causality model of use. • ‘Spectrum of Intervention’ model places great emphasis on the importance of prevention. • Introduces concept of risk management – importance in knowing proportion of population at risk in turn means most appropriate prevention strategies can be used. • In turn, this sets up potential for strong evaluation results. • Disadvantages: • Driven by focus on illness rather than on enhancing ‘wellness.’ • Emphasis on individuals/populations (less so on communities).

18. Universal Prevention • Targets an entire population • National • Local • Community • School or Neighborhood • Purpose is to deter the onset of substance use by providing the population with information and skills to prevent the problem. The entire population is considered at risk.

19. Steps in Developing our IOM Prevention Program for Universal Populations Group Exercise 1 • What Universal Populations do we want to focus our prevention efforts on? • Identify Universal populations • What prevention approaches might we use? • Identify different approach • Why were these approaches selected? • Alignment issue

20. Selected Prevention • You are at risk by virtue of membership in a particular segment of the population vulnerable to AOD abuse CSAP examples: • Children of Adult Alcoholics (COA’s) • Students who are failing • Youth who live in high drug use neighborhoods • Strategy/Approach targets the entire subgroup, regardless of the degree of risk of any individual within the group. • Participants are not assessed for specific individual risk factors, but are recruited/referred based on their membership.

21. Potential Selected Populations • Homeless • Young Offenders • Foster Youths • Drop-outs • Students with social/academic problems • Rave party-goers • Others

22. Factors for Creating Prevention Programs for Selected Populations • Identification of subpopulation: • Clear/difficult • Setting and Access • Alignment: • Needs of the subpopulation and the proposed prevention approach/strategy must align • One Example – Foster Youths

23. Foster Youths – A Vulnerable Population Selected → Indicated • Approximately 90,000 in Foster Care in California • Prognosis for Positive Future – Grim • 50% do not graduate from high school • 1 in 8 graduate from a 4 year college • Only 38% are fully employed 12-18 months after leaving program • Median salary less than full-time worker making minimum wage

24. Foster Youths – A Vulnerable Population Selected → Indicated • 1/3 of youths leaving foster care experience Emotional and Behavioral problems including: • Truancy • Social Withdrawal • Running Away • Engage in Risky Behaviors • 50% use drugs • 25% have encounters with CJS • Higher birth rates among young women (40-60% within 12-18 months leaving the system) • Many experience homelessness

25. Steps in Developing our IOM Prevention Programs For Selected Population Group Exercise 2 • Identification of Subpopulation • Is this an appropriate subpopulation? • Issues – Selected or Indicated or both? • Setting and Access • Where to go, Who to partner with? • What types of Prevention Approaches might we consider • Who should we target? • What approaches should we consider?

26. Indicated Prevention • Targets individuals who are exhibiting early signs of substance abuse and other problem behaviors associated with substance abuse including early substance use. • Examples: • Binge drinkers, High rate users • Strategy/approach must have screening process or other identification processes in place to identify these individuals. • The approach involves direct intervention but not formal treatment • Most ‘indicated’ are part of a selected subpopulation group.

27. Factors for creating Prevention Programs for the Indicated Population • Identification: • More difficult/complex than selected. • Access: • Will vary, more difficult than either universal or selected. • Approaches • Individualized • Costly • SAP’s represent possible approach for in-school populations.

28. Steps in Developing our IOM Prevention Programs For Indicated Populations Group Exercise 3 • What indicated populations in our community do we want to focus our prevention efforts on? • Identify Indicated populations. • State why they are indicated. • Where would we find them? • What Indicated prevention approached might we use? • Why were these approaches selected? • Alignment issue

29. IOM PreventionCircles within Circles Selected Subgroups Universal Populations Indicated Individuals

30. Intensity Versus Degree of Risk High Indicated Moderate Selected Intensity of Intervention Universal Low Low Moderate High Degree of Risk

31. Summary IOM approach requires: • Better understanding of our community – communities within communities. • Tired approach in thinking about prevention services. • U.S.I • Thoughtful application of prevention approaches to the three types of populations. But it gives us: • Better focus on AOD problems and individuals involved/impacted by AOD use. • Potentially better measurements of success.

32. Conclusion • Use the IOM model to define and target populations in need of prevention services. • Determine whether you are dealing with a Universal, Selected, or Indicated populations and what type of problem/condition they are (or could) experience. • Approaches that specifically meet the needs of the populations and AOD conditions of concern. • Identify potential collaborators/resources to engage in the prevention approach. • Develop a specific prevention plan for implementing the primary prevention plan. • Maintain and evaluate prevention outcomes. • Target, target, target.

33. This document is a product of the Community Prevention Institute (CPI), a project of the Center for Applied Research Solutions (CARS), to provide no-cost technical assistance and training to communities throughout California. CPI is funded and directed by the California Department of Alcohol and Drug Programs. For more information about CPI, go to: www.ca-cpi.org or www.cars-rp.org.