1. Prevention and wellness practices in a 21stcentury
environment; what we have and what we need
January, 2012
Author: Frank G. Magourilos, MPS, CPS, ICPS
Big Picture—in the last two decades the science of Behavioral Health Prevention has
advanced faster than our ability to systemically fund, absorb, and effectively utilize. We
finally understand through empirical supportive evidence, that in order to prevent and
reduce societal ills we must start early and well before the onset of the condition1.
Furthermore, we know that to really change the trajectory of any behavior we cannot only
work on the individual but we must also work to change the environment that the individual
lives in23. Given the notion that we have to work within the system of the individual along
with the system of the environment that also includes society as a whole, this provides the
prevention workforce incredible challenges. Clearly prevention, evidence-based,
successful prevention, is a very multifaceted ever changing construct which has certain
characteristics that not only prevention professionals need to understand but it is critically
important that society as a whole, organizations, management, and political leadership
need to also be aware of.
Evidence-based prevention characteristics—the field of prevention is immersed in a
disciplinary approach that utilizes many theories and models from many other sciences
such as; psychology, sociology, public health, and environmental sciences. Because a
human being and their environment are extremely complex systems45 the need for
academic professional prevention workforce development is paramount; yet the current
global prevention workforce system is one that allows individuals to enter the field with
nothing higher needed in most cases than a high school diploma. The skills and
competencies that are needed for today’s prevention professional to be successful are
daunting to say the least. Today’s prevention workforce to be effective needs to be well
versed on concepts, theories, and models such as; risk and protective factors theory6,
systems thinking, logic models, geo-political environments, issues, and policies, strategic
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2. planning, evaluation, facilitation skills, cultural sensitivity, behavioral models, sociology and
community engagement, mental health and abnormal behaviors, drug categories and
individual drug analyses, diffusion of innovation theory7, leadership theories,
developmental models and aging, social norms8, media and marketing strategies, gender
health and prevention, environmental approaches, integration principles, relationships
between substance abuse prevention and injury and violence prevention9.
The list can go on but I think my point is made, which glaringly eludes to the tremendously
extreme disparity between the degree of high, large, positive prevention results that are
expected from the public, managers, departments, politicians, organizations, local and
state governments, versus the reality of having a prevention workforce that is largely and
extremely ill prepared, under educated and under funded by hundreds of millions of dollars
just in New Mexico alone10. Under the current conditions how can we expect population
level change prevention results in underage drinking, DWI, drugs, and other risk categories
when Prevention funding has decreased by 61% (NM/BHSD/OSAP) in the past two years
in New Mexico? Furthermore, the average pay of our New Mexico prevention workforce is
less than 15 dollars per hour. Most do not have a bachelor’s degree and only one or two
have a degree specific to prevention. If a farmer planted seeds and never watered or
cultivated them would he be surprised at the results? It is quite apparent by the impossible
unfunded and under resourced demands put on the current prevention workforce, that our
leaders, funders, local governments, and many others do not understand why we are not
getting the results we all want.
Systems thinking; how other systems influence prevention—Systems thinking11 is the
process by which we attempt to expose the conditions supporting the problem or symptom
rather than merely reacting to it. Systems’ thinking considers all the intricately woven
factors and influences imposed upon the problem, issue, or opportunity and allow
examination of how each relates to the other and interacts as a whole. Rather than
breaking a problem or opportunity into small pieces and then isolating the pieces in order
to study them, arguably it is more useful to study the entire problem or prospect. In this
way patterns, trends, and systems emerge providing an opportunity to consider both the
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3. intentional and unintentional consequences of actions to be taken. It is far easier to get
caught in the reactive trap of addressing symptoms when one is focused on a small part
without the context of the bigger picture. What is important to understand is that
everything that we do in prevention is positively or negatively influenced by other systems
in our world that we may or more than likely may not have control over. Prevention is a
system, a school is a system, a government is a system, a family is a system, a community
is a system, a city is a system, politics in itself is a system, identified resources is a
system, networking partners is a system, a DWI Planning Council is a system, the Board of
County Commissioners is a system, and media is a system, just to name a few. All these
systems are open, perpetually changing, and interconnected; every time anything is
changed at any one system it affects all the other systems. These relationships need to be
understood and prevention strategies need to maximize any positive relational influences
that exist between systems while minimizing negative relational impacts to the extent
possible.
Prevention landscape needs a paradigm shift—as mentioned earlier and based on
empirical evidence there are many areas we need to work on if we really care to see
individual and population level change for a better future of our youth, elders, and all
members of a 21st century society. Below is a list of areas that need our immediate
attention:
Flavor of the month approaches—we have the tendency of collectively over reacting to
any new trend that comes along without strategically thinking the impact funding and other
resources would have by diverting from one area of prevention, such as curbing underage
and binge drinking to addressing for example prescription drug abuse; these tendencies
have a huge impact on the overall prevention landscape. A few years ago Meth was a
huge flavor of the month, currently it is prescription drugs, and other trends come and go.
Although I am not advocating that these trends not be addressed, my point is that our
prevention strategies have to be largely based on CORE-ROOT CAUSES while utilizing
risk and protective factors theory and other relevant research based principles. Just by
placing a huge amount of our resources on any one single trend we miss the big picture,
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4. which are the underlying reasons (individual and environmental) as to why youth and
others are looking to involve themselves in such ill, destructive behaviors in the first place.
Coordinated Statewide Prevention—although an argument can be made for having local
community level control of prevention programs, the research12 points out that unless there
is a central statewide entity, that may not necessarily control the funding, but rather
coordinates and guides prevention efforts, there will always be the silo effect of individual
programs working in segmented areas without cohesive, and collective system-wide
guidance, while always subjected to the mercy of uninformed community politics and
individual agendas. The local needs can always be met by having effective and research
based on-going community assessments13. A comprehensive needs assessment is the
critical first step a coalition or organization must take in order to develop an effective and
successful prevention effort. Furthermore, a comprehensive needs assessment achieve
results because the solutions are targeted at the real causes. By having a coordinated
statewide prevention effort many benefits would be realized:
• Partnerships between programs facilitate the sharing of information, materials, and
expertise.
• Integrates and maximizes resources.
• Facilitates complementary and supplementary programs.
• Leads to a system in which the whole is greater than the sum of its parts.
• The benefits of coordination are compelling and beneficial to the public.
• Increased capacity and improved quality of services to individuals and communities
because of shared knowledge and improved planning.
• Statewide prevention coordination largely eliminates political agendas, unwarranted
interference, and individual power plays at the local level.
• If there is to be a systems wide prevention integration approach, federal and state
coordination is absolutely critical.
Prevention and systems integration—in June of 2011 the Federal Government released
the first ever National Prevention Strategy14. The National Prevention Strategy’s vision is
working together to improve the health and quality of life for individuals, families, and
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5. communities by moving the nation from a focus on sickness and disease to one based on
prevention and wellness. This Strategy envisions a prevention-oriented society where all
sectors (systems) recognize the value of health for individuals, families, and society and
work together to achieve better health for all Americans. Aligning and coordinating
prevention efforts across a wide range of partners (systems) is central to the success of
the National Prevention Strategy. Engaging partners across disciplines, sectors, and
institutions can change the way communities conceptualize and solve problems, enhance
implementation of innovative strategies, and improve individual and community well-being.
Health and wellness are influenced by the places in which people live, learn, work, and
play. Communities, including homes, schools, public spaces, and work sites, can be
transformed to support well-being and make healthy choices easy and affordable. Healthy
and safe community environments include those with clean air and water, affordable and
secure housing, sustainable and economically vital neighborhoods (e.g., efficient
transportation, good schools), and supportive structures (e.g., violence free places to be
active, access to affordable healthy foods, streetscapes designed to prevent injury).
Healthy and safe community environments are able to detect and respond to both acute
(emergency) and chronic (ongoing) threats to health.
Making places healthier requires capacity for planning, delivering, and evaluating
prevention efforts. A prevention-oriented society can be supported by integrating health
and health equity criteria into community planning and decision making whenever
appropriate; maintaining a skilled, cross-trained, and diverse prevention workforce;
strengthening the capacity of state, tribal, local, and territorial health departments;
implementing effective policies and programs that promote health and safety; and
enhancing cross-sector data sharing and collaboration. This is the national vision
representing 17 heads of departments, agencies, and offices across the Federal
government who are committed to promoting prevention and wellness14.
Critically important to understand is the significant relationships between interdisciplinary
prevention professionals and all community partners. A wide range of actions contribute to
and support prevention, ranging, for example, from a small business that supports
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6. evidence-based workplace wellness efforts, to a community-based organization that
provides job training for the unemployed, to the parent of young children who works to
provide healthy foods and ensure they receive appropriate preventive services. Partners
play a variety of roles and, at their best, are trusted members of the communities and
populations they serve. Opportunities for prevention increase when those working in
housing, transportation, education, and many other sectors incorporate health and
wellness into their decision making.
Professional workforce development—arguably, this is the most important area that
needs to be addressed and brought forth to individual and community needs of the 21st
century. Many studies and assessments have been done in this area, and they all point
out the stark inadequacies of the workforce in the field of behavioral health prevention15.
Based on previous reports and reviews, barriers to strengthening the behavioral health
prevention workforce can be summarized as:
• Inadequate knowledge and expertise of the competencies the workforce needs to
meet current and future challenges.
• Lack in Identifying, Classifying, and Enumerating the Public Health Prevention
Workforce:
• Lack of clear, concise, public health prevention profession classification categories.
• A lack of a professional workforce education and expertise in advance
specialization areas and disciplines such as systems thinking, direct services,
environmental strategies, problem id and referral, policy and advocacy, community
private sector, public sector, and volunteer sector engagement.
• An absence of consistent public health professional credentialing requirements.
• Ineffective and inefficient training that mostly includes single-session didactic
workshops.
More critically, recent findings have exposed that today’s members of the prevention
workforce regularly struggle with the ambiguity of the rules, regulations, standards, and
procedures that manage service delivery, and which sometimes conflict with one another.
These rules may also not be grounded in an evidence base. They frequently limit
professional decisions and judgments, and can severely limit efforts to tailor interventions
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7. to individual need. Productivity is reduced because of administrative burdens, most notably
those involving extensive and often repetitive documentation. Members of the workforce
have repeatedly described their low morale and low levels of commitment to their
organization and to the field because of low pay, the absence of career ladders, excessive
workloads, tenuous job security, and an inability to influence the organization or system in
which they are working16171819.
Workforce potential solutions—we need to expand the current workforce capacity by
utilizing a system or a number of strategies that allow for a very broad-base empirical
prevention knowledge base across multiple disciplines. One way of accomplishing this
would be to infuse prevention core principles into existing curricula for teachers, doctors,
nurses, social workers, psychologists, and other human services professionals. This
would allow new professionals entering these fields to be equipped to utilize evidence-
based prevention practices into their sphere of influence.
There are also numerous prospects for increasing the knowledge base of the existing
human services workforce. Professional associations of teachers, school administrators,
social workers, nurses, doctors, psychologists, child welfare administrators, juvenile justice
administrators, and the public health field as well, can include information on evidence-
based prevention practices within their national conferences and continuing education
training courses. Federal agencies may also want to consider issuing workforce
development planning grants for states that are specifically focused on the area of
revitalizing and intensifying the prevention-based knowledge and competencies of their
workforce.
Cultivate and multiply prevention related partnerships and coalitions—a critical part
of workforce development and expansion needs to come from outside the normal
boundaries of the behavioral health field. There are simply not sufficient financial and
human resources to address such a complex problem as adverse human behaviors and
the environmental factors involved by simply doing what the current prevention field has
been doing; namely a small number of individuals attempting to prevent millions of youth
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8. and adults from risky behaviors while at the same time trying to stem the environmental
tides of risk factors such as poverty, media, music, Internet, and motion picture glorification
of alcohol, selfishness, and social permissiveness just to name a few. Having said this,
the solution is imbedded in the simple premise that health and wellness, including
behavioral health, is in the best interest of everyone and every sector of our social
environment. Promoting prevention and wellness initiatives are attractive because they
impact all aspects of societal functioning. For example, the case can be made that
businesses should play a vital role in prevention and wellness because it would greatly
influence their bottom line. Healthy and productive young people are a coveted resource
for today’s competitive world. Adults with children that have health insurance with their
employers would arguably have lower healthcare costs thus, reducing the premiums that
have to be paid by businesses. These are just a few examples of cost savings and
incentives for businesses to participate, support, advocate, and even partially fund
prevention and wellness. The same can be said for many other sectors in our
communities (systems); coalitions, clubs, civic organizations, public, private, non-profits,
volunteer, etc. need to be on the table, and a very specific targeted, sustainable effort
needs to take place to bring everyone on-board to infuse prevention and wellness into the
entire social environment.
Leadership—however, in order for such a wide net to be systematically and successfully
dispersed there has to be critical leadership and coordination from federal, state, and local
governmental agencies. The Affordable Care Act enacted in 2010 authorized the creation
of the National Prevention, Health Promotion, and Public Health Council, a body charged
with providing coordination and leadership at the federal level among executive
departments and agencies in relation to prevention, wellness, and health promotion20; this
National Prevention Council would be the logical place for providing leadership and
coordination in addressing the need for total community engagement, and in fact the
National prevention Strategy released in June of 2011and created by this Council calls for
just that. In addition, we will need to look at existing data systems that can be expanded to
include specific community sectors for process and outcome measures. There will also be
the need to look at available or create new evidence based programs and practices that
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9. are tailored to each community and business segment. Finally, we will have to look at
creating, improving existing and/or developing a segment of our prevention workforce that
would specialize in wide and far reaching relationship building and partner engagement
from all community sectors.
Another critical area that leadership has to be involved in is the prerequisite to have a
much focused mission and consistent strategy in the robust dissemination of prevention
research findings. From how prevention impacts human developmental stages and what
strategies are effective, to how systems and environmental interactions support or hinder
quality of life. Furthermore, prevention integration models that include cost and benefits
analyses need to be created and disseminated into the many different verbiage and
languages of business sectors and other organizational environments. To apply it
differently, prevention principles, practices, and core foundations will be disseminated
universally, however additional components such as how these principles, practices, and
policies will impact a particular sector of the economy or the social environment should be
disseminated to be understood by using the lingo of such sector it is intended for.
Resources—if there is fruition in the creation and implementation of a coordinated
sustainable prevention and wellness integration into every core and every component of all
the sectors that make up the systems that function as our social environments, then the
additional saved resources from lower health care and societal costs, along with the quality
of life improvements gained, will exponentially eclipse the resources needed to realize,
implement, and sustain this prevention integration systems approach.
Conclusion—clearly if we want to take advantage of the research and the recent
advances in prevention and wellness we have to also work on the implementation and
workforce development side of the equation. The logical place for the spark needed to
lead us into this direction is the National Prevention Council and the Substance Abuse and
Mental Health Services Administration, SAMHSA that has prevention as its top priority21,
their combined leadership would put the nation in a great position to advance prevention
services in all sectors of our social environment. Furthermore, the 2009 Institute of
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10. Medicine, IOM report27 along with the National Prevention Strategy provide the
foundational 21st century prevention and wellness roadmap to follow. Currently the
infrastructure necessary to broadly and expansively deliver prevention services is not
collectively been constructed, although most pieces already exist. It is time for a paradigm
shift in prevention and wellness, and the tipping point is within reach waiting for leadership
to strike the match.
References
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12. 19. Blankertz & Robinson, 1997b; Center for Health Workforce Studies, 2006; Gellis &
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About the Author
Frank G. Magourilos is a Sr. Certified Prevention Specialist with a Master’s Degree in
Prevention Science from Oklahoma University and Bachelor’s Degrees in Cognitive
Behavioral Psychology and Intercultural Communication from the University of New
Mexico. He is the Executive Director of the New Mexico Credentialing Board for
Behavioral Health Professionals, www.NMCBBHP.org and he is also the Founder of the
New Mexico Prevention Network, www.nmpreventionnetwork.org. Additionally, Mr.
Magourilos oversees all the Prevention Programming for the Santa Fe County DWI
Program and is a Technical Prevention Advisor for the New Mexico Department of Finance
& Administration Local DWI Programs.
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