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Sections updated and revised substantially to include recent developments and research. List of primary prevention centers added. Bibliography expanded and updated.

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Primary Prevention

Abstract and Keywords

Primary prevention involves coordinated efforts to prevent predictable problems, to protect existing states of health and healthy functioning, and to promote desired goals for individuals and groups, while taking into consideration the physical and sociocultural environments that may encourage or discourage these efforts. This entry discusses the history of this basic approach to professional helping from medical, public-health, and social-science perspectives. It also reviews major theories that guide preventive thinking and action. One section sketches the substantial empirical base for evidence-based practice and how such information can be retrieved. This entry concludes with a review of practice methods for increasing individual strengths and social supports while decreasing individual limitations and social stresses, which together characterize most contemporary preventive services.

Keywords: biopsychosocial–cultural perspective, ecological systems perspective, epidemiology, indicated preventive interventions, preemption, prevention, primary prevention, promotion, protection, incidence, prevalence, public-health theory, selective preventive interventions, social cognitive theory, strengths perspective, universal preventive interventions, wellness orientation

A Sense of the Term

Primary prevention involves actions taken by individuals and organizations to prevent predictable problems, protect existing states of health and healthy functioning, and promote desired states of functioning while taking into consideration supportive or harmful physical and sociocultural environments (Gullotta & Bloom, 2003; in press). This three-part definition extends beyond the lay meaning of prevention alone because something positive must often be promoted to take the place of something negative that has been prevented. Contemporary thought emphasizes the dynamic ecological perspective integrating preventive, protective, and promotive actions among individuals and groups and the settings in which they live (Durlak, 2003; Gullotta & Bloom, 2003; in press). Many significant elements in the social and natural environments may be used in achieving desired goals in primary prevention, rather than dealing only with personal factors surrounding an individual’s presenting concerns. Helping professionals have a role to play in creating and initiating primary prevention programs while respecting the strength of self-help groups and individual initiatives in directing their own lives toward positive goals. Issues involving primary prevention are often on a national or international scope, requiring prevention professionals to work with governmental and international organizations to address global concerns such as climate change, concerns over the health of children worldwide, the full equality of women and minority groups, and many social and environmental concerns.

History and Definitions

Primary prevention is a term rooted in ancient folk wisdom (such as “a stitch in time saves nine”) and continues in the early 21st century in almost every aspect of ordinary life, from frequent hand washing and safe food preparation (to prevent the spread of germs among individuals) to governmental regulations regarding air quality and highway safety (for the public good). These facets of everyday life are often based on sophisticated research and demonstration projects, but are frequently taken for granted until some breakdown in the routine calls attention to how much we depend on effective—and cost-effective—primary prevention measures (Kennedy, 2003; Yodanis & Godenzi, 2003).

Medicine’s long history included not only setting broken bones and discovering specific chemicals (herbs and drugs) and technologies that served specific uses, but also preventive medicine for addressing predictable illnesses before they occurred, in part because sustaining any injury or illness requiring then-primitive medical treatment often had deadly iatrogenic outcomes throughout most of history. However, preventive medicine effectively emerged with the development of germ theory, which viewed illness as caused by some microscopic entity in the individual, with the medial model corollary that only a specialist (the physician) could diagnose and treat these invisible entities (Leavell & Clark, 1953). The language of medicine “patients,” “compliance,” “doctor’s orders” indicated that the doctor knew what was best for the patient; it also indicated not so subtly the posture that consumers were supposed to take. The emphasis on microscopic entities tended to blind professionals to the massive social issues of poverty, crowding, and sanitation that were equally involved in causing health problems (Albee, 2003) and, thus, shifted blame to the victims of these social conditions.

Public health developed, in part, as a reaction against the limitations of a medical/germ model by recognizing that there are always three factors in any illness: the hosts or victims of the problem, the identifiable agent of the disease, and the environments in which the host and agent met with problematic outcomes. Any or all of these could be points of entry to address problems, which were seen as a population rather than as individual concerns (MacMahon, Pugh, & Ipsen, 1960). From this population perspective, great strides were made in the 19th and 20th centuries in some parts of the world to increase health and longevity by improving water quality, mass vaccinations, and sanitation systems. Individuals being treated in the early 21st century by their physicians for painful conditions may forget how important population-wide innovations and environmental changes have been in their own lives and the lives of millions of others.

Preventive psychiatry offered a new conceptualization of prevention, using as basic terms “primary prevention” (actions taken to reduce the incidence—new cases—of a problem), “secondary prevention” (actions taken to reduce the prevalence or number of existing cases), and “tertiary prevention” (actions taken to reduce the untoward effects of diseases that had been resolved to the extent possible) (Caplan, 1964). Although these distinctions throw light on the connection of incidence and prevalence, they inadvertently introduced misunderstandings of language, such as trying to prevent something that has already occurred. (The terms prevention, treatment, and rehabilitation provide a more direct statement of the helping situation.) This language still appears in contemporary writing, but not always with the clarity that its originators gave it. Other important preventive ideas emerged from this context. For example, “anticipatory guidance,” such as informing patients (or even presenting limited challenging experiences) of the stresses they will undergo in a future medical procedure, tend to reduce those stresses and improve recovery rates (Caplan; Poser, 1970; Poser & Hartman, 1979; Simon et al., 2006). Researchers with a learning-theory background expanded these ideas into other fruitful prevention projects, such as Spivak and Shure (1974), who investigated interpersonal problem-solving skills.

Epidemiology, the science of the distribution in time and space of elements of disease and health, provides strong tools in the analysis of human conditions, from the days of Dr. John Snow and the cholera epidemic in London in 1848 (based on epidemiological evidence alone, Dr. Snow removed the handle of a contaminated public water pump, even when the bacterial cause was unknown at that time) to the early 21st century, as in the analysis and resolution of the puzzling Legionnaire’s disease (Fraser & McDade, 1979), where a previously unknown pathogenic bacterium was identified through the use of epidemiological methods. Epidemiological types of investigations are used with issues such as schizophrenia (Boyle, 2004; Casstevens, in press), substance use (Mason, Cheung, & Walker, 2004), and HIV risk (Mitchell, Kaufman, Beals, & the Pathways of Choice and Healthy Ways Project Team, 2004).

Social psychology (and its modern descendants in environmental psychology, positive psychology, and community psychology) and social work have led in the emphasis on the health and strengths of people, which can be employed to address concerns and achieve desired goals, even in the face of serious problems. “Clients” and “consumers” have replaced “patients” in the vocabulary of social workers, reflecting participants’ important contributions in resolving their own concerns and achieving their goals (Bloom, 2010). A person(s)-in-environment(s) perspective is the mantra for social workers regardless of specialty. There is a wellness orientation, explicit in the work of psychologists Cowen (2000) and Durlak (1997), as well as Saleebey (1992) and others in social work, that builds on the strengths of people. Albee (1983; 2003) connects all expressions of professional helping—or more accurately, differential helping—with a just (or unjust) society, in which various minorities suffer at the hands of dominant self-interest groups, themes that resonate in social work with Jane Addams and the settlement house movement. However, this is not simply a problem for minorities. For example, Pollan (2007) discusses how eating healthy foods has been subverted by an overcompetitive food industry, an underprotective government, a reductionist nutritional science, and a co-opted mass media, leading to mass public confusion. His solution is to eat real foods (not processed or artificial ones), not too much (because we do not need as much as we have been eating), and mostly plants (cut down on red meat and dairy products).

Theories Regarding Primary Prevention for Social Work

Five general theories on primary prevention guide current social-work thinking, with other models seeking to amplify specific situations. First, the public-health theory, described previously, directs social workers to think beyond a specific problem for a specific person to see the contributions of the agent of disease, as well as the facilitating or resisting efforts of the environment itself. Moreover, the public-health model encourages interdisciplinary cooperation because epidemic-size problems or potentials know no professional boundaries.

A second general perspective might be termed the intervention target model (Compton, 2010; Gordon, 1983; Mrazek & Haggerty, 1994), which distinguishes three categories of intervention from a medical model perspective:

  1. 1. A universal preventive intervention targets the general public or a whole population that has not been identified as having individual risks, so that the intervention benefits everyone in the group. An example would be prenatal care for every child.

  2. 2. Selective preventive measures are procedures targeted to individuals or subgroups in a population whose risk of developing specific problems are higher than average. For example, social workers and visiting nurses might be involved in home visitation and infant care and training in social. development for low-birth-weight children of adolescent mothers.

  3. 3. Indicated preventive intervention would be employed with high-risk individuals having minimal but detectable symptoms foreshadowing mental disorders or for individuals showing biological markers indicating predisposition for mental disorders, but who do not meet DSM-III-R diagnostic levels at the current time (Mrazek & Haggerty, 1994, p. 25). An example is encouraging a person with a family history of schizophrenia to receive counseling in the early adolescent and adolescent years to monitor his or her behavior and, if necessary, receive an atypical antipsychotic medication to “prevent” the onset of this disorder.

This last example is both exciting and frightening. It is exciting that a serious mental-health issue might be avoided, but frightening in that our knowledge to make such determinations is embryonic. The specter of Nazi-like eugenics hangs in the background of this final example with its gruesome history of compulsory sterilization and massive extermination of “undesirable” people. Nonetheless, social workers must be aware of these three categories of universal, selective, and indicated preventive measures because they have become part of the federal funding landscape.

However, Insel (2008), then director of the National Institute of Mental Health, proposed to move away from universal prevention toward “preemption” (which essentially combines the selective and indicated categories as related to schizophrenia and bipolar disorders) because we may have reached the limit in dealing with environmental stresses. Whether this revised version of the medical model can address the enormous numbers of persons with serious mental and physical health issues by treating each individual one by one remains to be seen, especially given the small numbers of available and trained personnel [as Albee (1983) pointed out years ago] (also see Tilson & Gebbie, 2004).

A third theory involves a social cognitive theory (Bandura, 1986), which differs from the instinctive causation model of Freud and the external causation model of Skinner by including both internal cognitions and feelings (especially self-efficacy, the feeling that “I can do a specific action on my own behalf”) along with perceived rewards or punishments from the environment. This model has been used in many research projects that have guided social-work thinking (Bandura, 1986; 2004). It involves four kinds of helping actions: most effective are those that demonstrate to clients that they can master some part of the required task, which encourages them to go on and master other aspects. Vicarious awareness of the rewards and punishments meted to others who are like oneself in situations like one’s own is another strong influence. Weaker influences are verbal persuasions, whereas physiological reactions are underused, helping clients to be aware of internal reactions that may interfere with visible actions, such as some performance anxiety that can be reduced in part by deep breathing and relaxing before the performance. We will discuss how to translate these abstract terms into concrete action plans in a later section of this entry.

A fourth theory is the wellness model (Cicchetti, Rappaport, Sandler, & Weissberg, 2000; Cowen, 2000) or the strengths model (Durlak, 1997; Durlak & Wells, 1997; Saleebey, 1992); both argue that starting with psychosocial assets is just as effective as beginning with disease or limitations, and both are preferable to the costly experience of treating victims of disease one by one. Note that DSM-IV-TR does not even discuss health except as the absence of illness. There are vested interests preoccupied with individual and collective pathologies and the medicalization of many forms of personal expression (Frances, 2012). However, Cowen (2000, p. 482) points to research (Tolan & Guerra, 1994; Yoshikawa, 1994; 1995) suggesting that “effective early, comprehensive, family-oriented competence enhancement programs for preschoolers” were more effective in delinquency prevention than any specifically targeted adolescent program. In short, a promotive “jump-start” has the potential for forestalling diverse, maladaptive outcomes more than later prevention programs aimed at high-risk groups.

A fifth general theory follows from the work of George Albee, who offered what social workers would see as a biopsychosocial–cultural perspective on the nature of mental illness. Albee (1983, 2003) put the incidence of mental disorders into a formula, each point of which offers the potential for preventive intervention. What this formula suggests are the major causal sources of, and protections against, mental disorder. Social workers will be familiar with these biological, psychological, and sociocultural interventions, such as genetic counseling, talking therapies, employee assistance work, and social action against exploitations and discriminations based on ethnicity, gender, age, physical facility, or sexual orientations. The tools used to reduce these problematic factors include education, promoting social competency, natural caregiving, and community organization or systems (Gullotta, 1987).

What this biopsychosocial–cultural model is making clear is that no single level of focus will be sufficient to deal with the range of issues that any social problem involves. Our models of understanding (theories) must be as expansive and complex as the problems they are intended to address. Moreover, with the recent emphasis on evidence-based practice, these models or theories must rest on the best available empirical evidence.

There is yet another implication of this biopsychosocial–cultural model, which places primary prevention within the core of helping services that includes primary prevention, treatment, rehabilitation, and palliative care. What we see in practice is the combination of helping services called into play whenever the need arises. So, for example, Tadmor (in press) discusses services for a dying youth and his family (parents, siblings, and relatives) in which palliative care is being provided to the dying youth; preventive services are given to the siblings (anticipating problems related to the future death of their brother); rehabilitative services are given to the family to reconstruct itself in the wake of the coming death; and some treatment issues are addressed for some involved family members. All of these needs exist at the same time, and more than one professional helper would likely be employed to address them, with coordination among them. This is the real context of helping, wherein professional boundaries dissolve in the face of client-centered helping. This is not to deny any of the characteristic focus of the individual helping professions, but rather to emphasize that needs of clients may cycle among primary prevention, treatment, rehabilitation, and palliative care and each profession must be ready to cooperate and coordinate.

Evidence-Based Practice of Primary Prevention

The beginnings of the science of primary prevention are still very much present to recent generations of practitioners. The Journal of Primary Prevention is now in its 33rd year, whereas the American Journal of Public Health goes back about 100 years, and Prevention Science started only a dozen years ago. Since the 1980s, researchers from many fields have come together to construct a solid foundation, so much so that prevention’s most vocal critics in the area of counseling interventions and psychopharmacology find themselves in the embarrassing situation of knowing less about what works and may work (at least with regard to children and adolescents) than the preventionists they once so roundly criticized (Gullotta & Adams, 2005; Gullotta & Blau, 2007). Even so, evidence-based practice is in its early stages of development as we begin to see the outlines this research will take in the future. With this cautionary background, we present an overview of the knowledge base for primary prevention from our vantage point as editors of the second edition of the Encyclopedia of Primary Prevention and Health Promotion (Gullotta & Bloom, in press).

Recently, some 300 prevention specialists from around the world are publishing an extensive life span review of preventive and health promotive interventions. The Encyclopedia of Primary Prevention and Health Promotion (in press) will cover some 150 topics identifying, when possible, strategies that worked (based on three or more successful trials), strategies that are promising (based on some positive early results or research in a related field), and strategies that do not work. Not every topic area revealed programs that worked, although many did; however, all of the areas did suggest some promising leads that need independent confirmation.

It may be useful to list some of these topic areas so readers will comprehend the range of subject matter at their disposal. First, we present several examples of topics related to prevention: child abuse and neglect, motor vehicle accidents, aggressive behavior, asthma, attention deficit hyperactivity disorder, birth defects, cancer, chronic diseases, criminal behavior, delinquency, (psychological) depression, disordered eating behavior, divorce (preventing problems affecting children and adolescents), elder abuse, gambling, HIV/AIDS, unintentional injuries, intimate partner violence, loneliness or isolation in older adulthood, and obesity.

Topics related to promotion include academic success; successful adoption; work with African Americans, Asian Americans, Latinos/Hispanics, and Native Americans and Alaskan Natives; anger regulation; death with dignity; effective child care, environmental health; correcting racial and ethnic disparities; strengthening families; effective foster care; handling grief in older adulthood; prosocial behavior; and physical fitness and health. This is a partial list of topics, and because of page constraints, we will only illustrate what readers can find in one case example: the prevention of cancer in older adults.

Current Applications of Primary Prevention Knowledge—Case Example: The Prevention of Cancer in Older Persons

Bertera (in press) presents an important discussion on the prevention of cancer in older persons through nonmedical means. She follows the basic outline for the Encyclopedia of Primary Prevention and Health Promotion (2nd edition) by indicating the scope of the problem, current theories and research relative to work in this area, strategies that work, strategies that are promising, and strategies that do not work. We report some portions of her entry to give a sense of its contents and what readers can hope to find in other entries.

The scope of cancer among Americans is great, with an estimated 1.6 million new cases (2011), of whom about a half million will die from the condition. Sixty percent of new cases are in persons 65 and older; 60% of cancer survivors are in this same age group. Rates of cancer differ considerably among ethnic groups, socioeconomic status, and levels of education, among other factors. Hence, prevention planning must consider these factors in developing new programs.

The risks of developing cancer are well known: use of tobacco (to which 30% of all cancer deaths are attributable), obesity (about 15% of all cancer deaths), poor diet, physical inactivity, inadequate health insurance, and reduced access to preventive services. These factors differentially affect various social and economic groupings in society. The costs of the many people afflicted with these cancerous conditions are enormous, with regard to not only morbidity and mortality, but also quality of life to the individuals and financial costs to society.

What are some successful nonmedical strategies that prevent cancer? There are several strategies that work: dietary management is a cost-effective solution (Danaei et al., 2009), but disadvantaged neighborhoods remain a challenge, with their abundant fast-food restaurants and lack of quality fresh fruit and vegetable stores, as well as safe places to exercise. Smoking cessation programs for older Americans are effective, although this is a challenge for the 4.5 million elders who smoke (and have smoked throughout their lives) (cf. Fiore et al., 2008). Screening programs are useful to catch problems at early and treatable stages (Afable-Munsuz, Liang, Ponce, & Walsh, 2009), yet even here, culturally sensitive and appropriate measures must be taken to bring prevention services to older adults.

Additional programs look promising in their early stages, such as phone-based or web-based interactive methods. Strategies that do not work include those with information only and those with little sensitivity to the populations being served.

In short, important information exists for nonmedical practitioners to affect this major health problem in the United States. The Encyclopedia of Primary Prevention and Health Promotion, 2nd edition, will be a useful resource for both students and practitioners.

Resources on Prevention

Information available on primary prevention has increased enormously since the turn of the 21st century. A number of journals are dedicated in whole or in large part to primary prevention, including the American Journal of Community Psychology, American Journal of Epidemiology, American Journal of Orthopsychiatry, American Journal of Public Health, Community Mental Health Journal, Health and Social Work, Health Policy Quarterly, Hospital and Community Psychiatry, Journal of Community Psychology, Journal of Health and Social Behavior, Journal of Preventive Psychiatry, Journal of Primary Prevention, Journal of School Health, Prevention in Human Services, Prevention Science, Preventive Medicine, Public Health Reports, and Social Policy, Studies in Crime and Crime Prevention.

In other mainline journals, such as Social Work, Social Service Review, American Psychologist, Psychological Bulletin, American Journal of Sociology, and Social Welfare, there are occasional articles relevant to primary prevention. As this listing makes clear, social-work users must be prepared to read interdisciplinary materials and to interpret their findings within the social-work ideology and context. The current and future generations of social-work students will know how to use search engines to locate studies on specific topics and will download these papers directly. This development will completely change the nature of, and expectations for, empirically supported information in primary prevention as well as other areas of social work.

Another resource is the Prevention Research Centers program, administered and funded by the Centers for Disease Control and Prevention, in which 37 academic centers around the country partner with organizations in their community using their expertise on such problems as controlling obesity, cancer prevention, and enabling healthy aging. This partnership work is done with underserved communities (such as Hispanics, the elderly, and rural people) with members of these communities involved in research that is intended to benefit these people. For example, a program entitled CATCH (Coordinated Approach to Child Health) followed a Texas law mandating all elementary school children have a health curriculum, physical education, and a school lunch program, with family involvement. A 3-year randomized controlled trial was conducted in 56 intervention schools and 40 control schools across several states (Texas, Minnesota, California, and Louisiana). The findings were strong, with physical activity up and fat consumption (and the proportion of overweight children) down in intervention schools, but not in the control schools. These kinds of findings were widely disseminated and now the state of Texas requires 30 minutes of physical exercise a day for all schools; some 750,000 students are involved in some 1,500 schools, as reported by Hawkins-Cox, Harris, Brownson, Ammerman, and Gray (in press). The names of these 37 centers and their focal activity are spelled out in the Hawkins-Cox et al. entry.

The amount and variety of information available on all types of primary prevention topics is staggering. Fortunately, many avenues exist to locate and access this information. The illustrations provided here are merely beginning points to retrievable information.

SAMHSA is the government’s Substance Abuse and Mental Health Services Administration. It has performed an enormous service to help professionals and consumers connect with relevant information. SAMHSA’s Guide to Evidence-Based Practices on the web is a good place to begin. It lists preventive and treatment sites; we will focus on the prevention of mental-health disorders. After a rigorous search and evaluation of available websites, they provide a listing of hundreds of sites beginning with the Campbell Collaboration, the Center for Evidence-Based Practices: Young Children with Challenging Behaviors, and the Center for the Study and Prevention of Violence. Each website is briefly described, such as the website Social Programs That Work, whose mission statement contains the following ideas: given that social programs in the United States are often implemented with little regard to rigorous evidence, while costing billions and yet failing to resolve critical needs, this website summarizes findings from well-designed, randomized controlled trials that may have important policy implications.

SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP) contains some 240 programs that have received governmental funds and are ready for dissemination to other users. One would perform a basic search using key terms to locate documented interventions. (Users can also receive updates by e-mail and even contact NREPP for some topics not found in the listing.) There are also advanced searches, sorted by areas of interest, outcome categories, geographic location, age groups, race and ethnicities, setting, and gender.

For example, the Family Foundation was described in September 2011 as a project with adult couples expecting their first child. The project was designed to promote positive parenting skills and adjustment skills for the physical, mental, and emotional challenges of parenthood. The experimental project is described and outcomes are reported—the intervention group performed better (p < .05 to p < .011) than the comparison group at 6 months, 1 year, and 3 years later. Contact information on principal investigators is given. NREPP also evaluates the quality of the research, relevant costs, and other useful information for each project.

Recognizing the changing face of mental-health services, SAMHSA also has a Consumer-Operated Services Evidence-based Kit. For example, Side by Side is a peer-based support group for persons with various mental-health concerns. It is an egalitarian, nonbureaucratic, affordable service that does not rely on professionals, but focuses on empowerment and caring. Various kinds of information are provided, including videos of working groups like Side by Side. (See also, for example, Fisher & Chamberlin, 2004.)

SAMHSA also recognizes that there are people who do not want to go to either a helping professional or a self-help group. For these people, SAMHSA commissioned Action Planning for Prevention and Recovery: A Self-Help Guide, a readable, short brochure presenting a common-sense approach to troubling issues a person might experience. The guide suggests the user set up a notebook with five sections, beginning with the person writing down (1) some wellness goals and (2) a daily maintenance plan to achieve them. (Examples are provided to users throughout the guide.) (3) The guide asks the person to think about trigger situations associated with the problems being experienced and also to list things that would help to avoid such situations. (4) In the next section the individual lists early warning signs of more serious problems and also how to deal with them, using stronger helping tools. (5) The final section discusses crises and how to plan to deal with them, using professional help. (SAMHSA does not endorse this guide, but offers it as one approach to self-help.)

The Practice(s) of Primary Prevention

There are two issues regarding practice methods in primary prevention. The first concerns what specific methods are available to help students and practitioners develop skills to deliver in appropriate situations. We can distinguish between methods that increase individual strengths and social supports and methods that decrease individual limitations and social stresses. It is beyond the scope of this entry to present a comprehensive report on methods, but we will indicate some representative practices.

To increase individual strengths, the following methods have been used in many research projects and are well developed in manuals (Albee & Gullotta, 1997; Gullotta & Bloom, in press; Bloom, 1996): preventive problem solving, anticipatory guidance, promotion of optimism, social skills training, nutrition and lifelong exercise, immunization, affective education, and assertiveness training.

To decrease individual limitations, practitioners have used cognitive reframing, thought stopping, stress inoculation, accident prevention training, relapse prevention, genetic counseling, relaxation training, stress management, and parent effectiveness training.

To increase social supports, the following methods have been employed: peer tutoring, bonding, encouraging friendships, social support networks, self-help groups, social empowerment, and institutionalized efforts to attain desired ends.

To decrease social stresses, social action, ombudsman programs, and social justice efforts, among others, have been used (Bloom, 1996).

The second issue regarding practice methods in primary prevention involves translating theory and research from non-social-work domains into usable social-work practice. Efforts must be made to translate unfamiliar language into terms that are comprehensible and usable by social workers by operationalizing the major concepts and propositions into specific actions a practitioner must facilitate. The development of practice manuals in various demonstration projects will greatly aid in this effort.

For example, consider Bandura’s (2004) social cognitive theory with particular reference to the concept of self-efficacy. As mentioned previously, Bandura points out four primary ways to influence this all-important factor in changing behavior: mastery, vicarious learning, persuasion, and physiological awareness. One case example he uses concerns Bill, a youth who is embarrassed in an English class when he does not know the answer to a question on Romeo and Juliet regarding the causes of the ensuing tragedy. In reaction, he insults the teacher and vows to drop out of school because of the stresses of this situation. However, Bandura emphasizes it is not the magnitude of the stress, but rather Bill’s capacity to cope successfully with any size of stress, that is at issue. Thus, he suggests several ways to help this student in this class, but also in school in general.

The first abstract term, mastery, refers to a person’s being able to perform some portion of the larger task successfully. Begin with a small but important part of the whole task, where the student can provide the correct answer. For instance, what are the ages of Romeo and Juliet, and what does this suggest for making important decisions on love, on violating parental demands, on death? Most young people can empathize with the Shakespearean characters on these matters. Then the teacher can introduce similar questions that build on prior successful answers to construct a case for responding to the overall question.

A second abstract strategy involves vicarious learning, which translates into an experience where the learner observes fellow students struggling successfully with attempts to construct an answer to the main question and then learns from others’ approaches to the task. For example, one girl in the class may be commenting on the subordinate role of young girls in the time period 500 years ago, where parental demands were law, compared with young boys who were freer from such rules. The penalties for violating these social mores become points of departure for considering the larger question of the ensuing tragedy. Bill can relate to this comment with his own thoughts on the roles of males, then and now.

A third abstract strategy involves persuasion, or telling someone that he or she has the capacity to achieve some goal. Unless supported with a history of mastery or the vicarious learning from fellow students, this method is relatively weak. The fourth abstract strategy involves physiological responses, such as taking a deep breath before answering a question, which can reduce anxiety to some degree.

The point of this discussion is to see how abstract terms can be accurately translated into here-and-now actions that the teacher, student, and class can perform in achieving the learning goal. Putting most effort into mastery and vicarious learning would seem to have more payoff than using the other two methods.

The Past, Present, and Future of Primary Prevention in Social Work

Ancient History: The New York Society for the Prevention of Pauperism (1817–1823) and the New York House of Refuge (1824–1934)

Social-work historians generally mark the beginning of social work in the late 19th century, with Jane Addams and Mary Richmond, whereas we find the beginnings of primary prevention a half century earlier, in the formation of the New York Society for the Prevention of Pauperism (SPP) in 1817 (Bloom & Klein, 1995–1996). This organization was based on an elementary but identifiable scientific theory, empirical research, a practice technology, a strong value stance, and a self-critical adaptive facility. The SPP found many causes of poverty rather than a single cause. For each suggested cause, a study group was set up to understand that condition and propose methods for preventive, not ameliorative, action. The SPP pioneered a system of district visitors in America (borrowed likely from German models—the three founding members of SPP were in close contact with European thinking and programs); the evolution of this idea continued in the Association for Improving the Conditions of the Poor (1843) to the Charity Organization Society (1888) and into our own times. However, the SPP was organized to “strike at the roots of those evils” (Pumphrey & Pumphrey, 1961, p. 61) responsible for causing new generations of paupers and started several organizations to do this, including a savings bank for working people, initiated efforts to coordinate charitable contributions, established a library for working people, attempted to set up a winter fuel program for summer subscribers, and sought ways to provide employment for those who could not find it, “either by the establishment of houses of industry, or by supplying materials for domestic labor” (Pumphrey & Pumphrey, p. 62). However, the SPP took on more than it could manage, and through critical self-appraisal, it reformed and focused all its efforts on a new enterprise, the New York House of Refuge (1824), a rehabilitation center for juveniles in danger of committing serious adult crimes. This organization lasted more than a century.

Current Realities: Social Work and Primary Prevention in the Early 21st Century

Primary prevention is inherently interdisciplinary, given the complexity of the issues involved. In the social welfare area, social work is often the lead helping profession, but it is surrounded by vital secondary services, fiscal, genetic counseling, legal, and others. On the other hand, social work has a long tradition of being a secondary profession within other dominant helping settings, such as hospitals or schools. Occasionally, social workers suggest modifications that make the dominant approach more humane and client friendly (Tadmor, 2003)

In primary prevention, it is likely that social work will continue to provide secondary assistance for the near future until it formulates programs that have demonstrated effectiveness for the community at large.

Future Aspirations for Primary Prevention: Optimistic Forecast

The passage of the Health Care Act in 2010, and its upholding by the Supreme Court in 2012, will mean a major change in preventive thinking and action (assuming that the law is not repealed). To gain some control over spiraling health-care costs and in the face of massive increases of obese adults and children (and the medical consequences of this condition), one provision of this act requires participants to get physical exams, which could lead to advice on preventing predictable problems, as well as promoting a healthy lifestyle. Other provisions may also lead individuals to better health. The full implications of this law will require years to observe completely. However, it is a fruitful time for primary preventers to engage the hearts and minds, as well as the bodies, of the general public, for which new ideas and strategies will be needed. Each of prevention’s delivery mechanisms provides numerous opportunities for social workers to develop expertise to forward the movement of a healthier society.

Capturing the Enthusiasm of New Generations of Students for Primary Prevention

Many students enter social work with the anticipation of working with individual clients in treatment contexts. Yet when asked, many students profess interest in working to prevent predictable problems, protect existing states of help, and promote desired client goals. Probably the best strategy at this time is to connect primary prevention with the main body of social-work practice, as another tool in the armamentarium of the versatile helping professional in social work, while increasing knowledge of the theories, research, and practice in primary prevention as such. As financing of public programs becomes increasingly tight, policy makers will be forced to address the obvious, that dollars spent preventing problems will be better spent than dollars used to treat victims of preventable problems and to repair the social fallout of their problems.

Distinctiveness and Similarities of Primary Prevention Compared with the Other Helping Approaches

The major differences among the helping approaches rest on when services are delivered and by whom and the social and personal resources that can be used with the service. With primary prevention, we can often facilitate the participation of clients on their own behalf to prevent problems and promote goals. It is easier for clients to look forward to continued health and desired objectives than to accept psychosocial efforts after the problems have occurred. All social-work helping approaches share a generalized problem-solving approach of assessing the person(s)-in-environment(s), so as to get the greatest hold on the challenge facing the helping professional. There are many specific differences in theories and practice methods, but these are not nearly as important as the similarities in objectives and the underlying problem-solving process. The basic question is how to get prevention, treatment, and rehabilitation to work together for the good of their clients (Alexander, Robbins, & Sexton, 2000).


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                                                                                                          Further Reading

                                                                                                          Boston University, School of Public Health, Partners in Health and Housing Prevention Research Center:

                                                                                                          Case Western Reserve University, Prevention Research Center for Healthy Neighborhoods:

                                                                                                          Columbia University, Harlem Health Promotion Center:

                                                                                                          Dartmouth College, Prevention Research Center:

                                                                                                          Emory University, Prevention Research Center:

                                                                                                          Haney, P., & Durlak, J. A. (1998). Changing self-esteem in children and adolescents: A meta-analytic review. Journal of Clinical Child Psychology, 27, 423–433.Find this resource:

                                                                                                            Harvard University, Prevention Research Center on Nutrition and Physical Activity:

                                                                                                            Johns Hopkins University, Center for Adolescent Health Promotion and Disease Prevention:

                                                                                                            Morehouse School of Medicine, Prevention Research Center:

                                                                                                            New York University School of Medicine, Health Promotion and Prevention Research Center:

                                                                                                            Ohio State University, Prevention Research Center:

                                                                                                            Oregon Health and Science University, Center for Healthy Communities:

                                                                                                            Saint Louis University and Washington University in St. Louis, Prevention Research Center:

                                                                                                            San Diego State University, San Diego Prevention Research Center:

                                                                                                            Texas A&M Health Science Center, Center for Community Health Development:

                                                                                                            Tulane University, Prevention Research Center:

                                                                                                            University of Alabama at Birmingham, Center for the Study of Community Health:

                                                                                                            University of Arkansas for Medical Sciences, Arkansas Prevention Research Center:

                                                                                                            University of Arizona, Arizona Prevention Research Center:

                                                                                                            University of California at Berkeley, Center for Family and Community Health:

                                                                                                            University of California at Los Angeles, UCLA/RAND Center for Adolescent Health Promotion:

                                                                                                            University of Colorado at Denver, Rocky Mountain Prevention Research Center:

                                                                                                            University of Iowa, Prevention Research Center for Rural Health:

                                                                                                            University of Kentucky, Rural Cancer Prevention Center:

                                                                                                            University of Maryland, Prevention Research Center:

                                                                                                            University of Massachusetts Medical School, Prevention Research Center:

                                                                                                            University of Michigan, Prevention Research Center of Michigan:

                                                                                                            University of Minnesota, Healthy Youth Development Prevention Research Center:

                                                                                                            University of New Mexico, Division of Prevention & Population Sciences:

                                                                                                            University of North Carolina at Chapel Hill, Center for Health Promotion and Disease Prevention:

                                                                                                            University of Pittsburgh, Center for Healthy Aging:

                                                                                                            University of Rochester, National Center for Deaf Health Research:

                                                                                                            University of South Carolina, Prevention Research Center:

                                                                                                            University of South Florida, Florida Prevention Research Center:

                                                                                                            University of Texas Health Science Center at Houston, Prevention Research Center:

                                                                                                            University of Washington, Health Promotion Research Center:

                                                                                                            West Virginia University, Prevention Research Center:

                                                                                                            Yale University, Yale–Griffin Hospital Prevention Research Center: