American Journal of Community Psychology April 1997 v25 n2 p221(6) Page 1

A policy perspective on prevention.

by Patricia J. Mrazek and Michael Hall

Advances in prevention science has led to various opportunities for the creation of several
research including the meta-analytic review conducted by Joseph A. Durlak and Anne M. Wells.
However, public policies expected to support training, expansion and coordination of research
and transfer of knowledge have lagged behind as prevention science grows. It has been
constantly bothered by political and fiscal issues.

© COPYRIGHT 1997 Plenum Publishing Corporation have specific goals and multicomponents. It is helpful to
remind ourselves of the shortcomings of the research
In some ways it is the best of times for prevention, and in programs that have data currently available and why
some ways it appears to be the worst. Never before has Durlak and Wells singled out these areas as needing
prevention science been so strong. The advances that improvement. The sample sizes of the 177 programs in the
have been made, and the opportunities that exist were well meta-analysis were quite small. Seventy-one percent of
documented in the Institute of Medicine (Mrazek & the studies involved samples of less than 100 subjects,
Haggerty, 1994) report Reducing Risks for Mental and about one-half of these involved samples of 50 or
Disorders: Frontiers for Preventive Intervention Research. less. Sixty-four percent of the programs did not have
The meta-analytic review by Durlak and Wells (1997) is specific goals (which left the investigators a lot of leeway
based on somewhat different definitions and an alternative for determining what positive outcomes they would report).
classification of interventions, but it too provides the reader Seventy-five percent of the studies did not collect any
with an upbeat cautious optimism regarding the future and follow-up information. Follow-up of 1 year or longer was
the relevance of prevention research. completed in only 8 of the 177 studies.

Despite this optimism about the science of prevention,
public policies to support the training of more investigators,
the expansion and coordination of research across federal
agencies, and the transfer of knowledge into large-scale
field trials and service have lagged far behind what was
recommended by the IOM. As prevention begins to gain
some long-sought credibility within the mental health
community, it has faced more difficult political and fiscal
climates than what existed when the Senate
Appropriations Committee mandated the IOM study. The
change of leadership in Congress in 1996 reoriented the
political debate, and the issues of highest importance
included downsizing and reengineering the federal
government, decreasing budgets and eliminating
programs, shifting responsibilities from the federal
government to the states, and managing health care by
curtailing services and costs. Prevention service programs
took a back seat, a very far back seat. When new
programs were recommended, such as "midnight
basketball" in the crime bill, they were often criticized as
"pork-barrel," "do-gooder" notions with no merit. Advocacy
for prevention research has been exceedingly difficult in
the midst of this ever-changing and skeptical political
landscape.
The methodological shortcomings of these studies justifies
some skepticism regarding the benefits of primary
prevention programs. However, the authors compare the
outcomes to other established preventive and treatment
interventions in the social sciences and medicine, and the
benefits of primary prevention programs for behavioral and
social problems in children and adolescents are of similar
or higher magnitude. What the authors do not address,
and what scientists in these other research fields are sure
to raise, is the comparison of methodological shortcomings
across fields. If the experimental design is stronger in
these other areas, and especially if the positive results are
found to hold up over time, the mean effects take on
another level of significance. Nevertheless, prevention of
mental disorders is a young research field, and its
investigators are committed to raising the standards of
evidence. In one specific area - transition programs
targeting first time mothers - the outcomes are remarkable,
and Durlak and Wells found them to be among the most
effective of all preventive interventions (mean ES = 0.87).
The methodological rigor and long-term follow-up of some
of these programs, such as the Prenatal/Early Infancy
Project developed by David Olds, are fine examples of
what is possible in this field.

CAUTIOUS OPTIMISM IS THE KEY INFLUENCING POLICY

Durlak and Wells (1997) have provided background data
to support their recommendations for improvements in the
quality of prevention research. Specifically, they
recommend that sample sizes be larger, that there be
more follow-up studies, and that the intervention programs
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Policy issues at the federal, state, and local levels of
government and within service agencies and academic
institutions are quite similar. The first and perhaps most
critical step in gaining support from policy makers is to
help them understand what prevention is and how a
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American Journal of Community Psychology April 1997 v25 n2 p221(6)
A policy perspective on prevention.
preventive process works, whether the target population is
a whole community, a high-risk group, or individuals who
are already demonstrating some early symptoms or
difficulties. To most decision makers prevention implies a
long-term process with nebulous results. The concepts of
risk reduction, protective factor enhancement, and
proximal outcomes are critical to an improved
understanding. As Durlak and Wells (1997) note, ". . .
while prevention over the long term may be the ultimate
goal, in the interim it is important to document that the
intervention has an immediate positive impact."
The reviewers limited the scope of their analysis to
programs designed to prevent the onset of behavioral and
social problems in children and adolescents. They
specifically excluded educational interventions designed
exclusively to affect academic achievement and
interventions designed to prevent drug use. Even though
this is a legitimate way to narrow the huge task they faced,
it also represents one of the main problems in prevention
science today, that is, the categorical approach to mental,
social, educational, behavioral, and legal problems. Many
of these problems have common risk factors that interact
in complex causal chains. Addressing clusters of risk and
protective factors increases the chances of preventing
multiple problems in many areas of functioning. It is the
accumulation of multiple proximal outcomes across
various domains of functioning, such as educational
status, social adjustment, and behavioral and emotional
well-being, that will be the most convincing arguments for
the effectiveness of prevention.
The immediate next question from policy makers, whether
they are being asked to support research or services, is
related to cost and cost-effectiveness. Unfortunately,
Durlak and Wells make no mention of this issue anywhere
in their meta-analysis. In part this reflects the state of the
science: that is, there is scant evidence regarding basic
costs or the cost-effectiveness of prevention programs.
Even though it seems logical that preventive interventions
will be cost-effective in the long-run, empirical evidence is
needed. (The reader is referred to the IOM report for a
fuller discussion of this issue, including some examples of
cost-effective programs.)
Coordination of prevention programs across justice,
education, mental health, health, and other relevant
agencies or departments is greatly inhibited by the lack of
infrastructure. Many state governments used to have
Offices of Prevention that could have facilitated such
coordination, but for the most part these offices have been
dismantled. Individual institutions have always been
concerned about turf and protecting their own theoretical
viewpoint, but as budgets are being slashed everywhere,
the walls between institutions are higher than ever as
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Page 2
everyone is busy protecting their own programs. It appears
that one of few solutions will be to increase financial
support to those institutions that do decide to dovetail and
piggyback their work with each other.
FEDERAL LEGISLATION FOR PREVENTION SCIENCE
Important gains have been made in fulfilling some of the
main recommendations of the IOM study. The IOM
Committee believed that coordination of prevention
research and services across the Federal government and
training of prevention researchers were the two highest
priorities within an action agenda. With support from the
National Mental Health Association, the National
Prevention Coalition, the American Psychological Society,
the American Psychological Association, and the William
T. Grant Foundation, prevention science advocates have
been actively pursuing Federal legislation to being to fulfill
the coordination and training recommendations.
Agreement of the 27 professional organizations in the
National Prevention Coalition to coalesce around
prevention issues was a vital step toward implementation
of the IOM recommendations. Fortunately, many of these
issues have received bipartisan support in Congress. The
following legislation was approved in appropriations bills in
1996:
1. The Senate Departments of Labor, Health and Human
Services, and Education and Related Agencies
Appropriation Bill (Calendar No. 189, Report 104-145, to
accompany H.R. 2127):
In keeping with the Committee’s interest in NIMH support
for prevention research, the Committee commends the
NIMH for developing an implementation plan to address
the recommendations of the 1994 Institute of Medicine
report: ’Reducing Risks for Mental Disorders: Frontiers for
Preventive Intervention Research’ and urges timely
implementation by NIMH of two areas of prime importance.
First, to meet the need to train mental disorder prevention
researchers, the Committee supports NIMH in expanding
funding for the B-START program, both for those at the
beginning stages of their career and for career transitions
to behavioral science research. Second, the Committee
urges NIMH to take the lead in coordinating efforts to
prevent mental disorders, including support for an Institute
of Medicine round table created for this purpose.
2. The Senate Treasury, Postal Service, and General
Government Appropriation Bill (Calendar No. 157, Report
104-121, to accompany H.R. 2020):
For years complaints of duplication of effort and duplicative
programs abounding in government have been the topic of
discussion. As the Government moves toward a balanced
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A policy perspective on prevention.

budget, these problems become more apparent. A classic
example is the 1994 Institute of Medicine (IOM) Report,
’Reducing Risks for Mental Disorders: Frontiers for
Preventive Intervention Research’ which documents the
uncoordinated research and service efforts that now exist
in 23 Federal agencies in this field. The Committee
believes that efforts to coordinate these activities would
result in both financial savings and improved science. This
is only one example of many. The Committee urges OMB
to coordinate efforts in the prevention of mental disorders
that now exist across the various Federal agencies, and to
apply lessons learned wherever applicable.
3. The House of Representatives Departments of Labor,
Health and Human Services, and Education, and Related
Agencies Appropriation Bill (Report 104-209, to
accompany H.R. 2127): (The working is exactly the same
as the Senate’s version, listed above, but with one
exception. The last sentence reads somewhat differently.)
"Second, the Committee urges NIMH to take the lead
among Federal research agencies in coordinating
research efforts to prevent mental disorders."
4. The House of Representatives Treasury, Postal Service,
and General Government Appropriations Bill (Report
104-183, to accompany H.R. 2020):
The Committee is aware of the 1994 Institute of Medicine
(IOM) report, ’Reducing Risks for Mental Disorders:
Frontiers for Preventive Intervention Research’ that
documents the uncoordinated research and service efforts
that now exist in 23 federal agencies in this field. The
Committee believes that efforts to coordinate these
activities would result in both financial savings and
improved science and concurs with the IOM findings that
Executive Branch leadership to coordinate this field is
critical for the efficient expenditure of federal funds. The
Committee urges OMB to coordinate efforts in the
prevention of mental disorders that now exist across the
various federal agencies.
NIMH’s commitment and has designated prevention as
one of three main areas for review within the Institute. He
also has made a commitment for NIMH to play a major
role in organizing the collaboration meetings across the
federal agencies.
These gains in legislation and agency involvement are
encouraging, but the sobering reality is that, since the IOM
report was released in early 1994, there have been almost
no new federal dollars for the training of new investigators,
the expansion of research, or the transfer of current
knowledge into service, and the coordination of prevention
research and service which is fragmented across the
federal government is still just a concept. There can be no
doubt that advocacy to influence prevention policy must
continue.
REFERENCES
Durlak, J. A., & Wells, A.M. (1997). Primary prevention
mental health programs for children and adolescents: A
meta-analytic review. American Journal of Community
Psychology, 25, 115-152.
Mrazek, P. J., & Haggerty, R. J. (eds.) (1994). Reducing
risks for mental disorders: Frontiers for preventive
intervention research. Washington, DC: National Academy
Press.

In response to this legislation, the Office of Management

and Budget agreed to provide oversight on the
coordination issue, and the Department of Health and
Human Services requested that the National Institutes of
Health host a government-wide forum and a collaborative
series of meetings to share information on programs and
coordinate the currently fragmented efforts in prevention of
mental disorders research that now exist at several
departments and agencies.

For many years Congress, professional organizations, and

advocacy groups have pressured, NIMH to assume a
more active role in prevention research. The Institute’s
new director, Steven Hyman, has been reassessing

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