10

Designing, Conducting, and Analyzing Programs Within the Preventive Intervention Research Cycle

Commissioned papers for this chapter were prepared by H. Kraemer and K. Kraemer and by S. Fawcett and colleagues and are available as indicated in Appendix D.

Successful science benefits from cumulative progress, and the field of prevention of mental disorders is no exception. The previous chapters have detailed the progress to this point, including the diverse lessons that can be taken from other areas in health research. It is apparent from the review in Chapter 7 that an encouraging number of well-designed research programs on the reduction of risk factors associated with the onset of mental disorders do exist. The task over the next decade will be to enlarge that body of work into a prevention science by instituting rigorous standards for designing, conducting, and analyzing future preventive intervention research programs. By adhering to such standards, prevention can achieve the credibility and validity necessary for its interventions to reduce the incidence of mental disorders.

Only rigorous standards can lead to an enrichment or expansion of the knowledge base essential for prevention efforts. Outcomes from trials built on such standards can serve to refine hypotheses and concepts related to risk and protective factors. The model building and hypothesis testing inherent in prevention research can elucidate pathways taken by individuals as they move toward or away from the onset of a mental disorder, as well as intervening mechanisms and brain-behavior-environment interactions that result in mental disorders or avert their occurrence, even in individuals at very high risk. In addition,



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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH 10 Designing, Conducting, and Analyzing Programs Within the Preventive Intervention Research Cycle Commissioned papers for this chapter were prepared by H. Kraemer and K. Kraemer and by S. Fawcett and colleagues and are available as indicated in Appendix D. Successful science benefits from cumulative progress, and the field of prevention of mental disorders is no exception. The previous chapters have detailed the progress to this point, including the diverse lessons that can be taken from other areas in health research. It is apparent from the review in Chapter 7 that an encouraging number of well-designed research programs on the reduction of risk factors associated with the onset of mental disorders do exist. The task over the next decade will be to enlarge that body of work into a prevention science by instituting rigorous standards for designing, conducting, and analyzing future preventive intervention research programs. By adhering to such standards, prevention can achieve the credibility and validity necessary for its interventions to reduce the incidence of mental disorders. Only rigorous standards can lead to an enrichment or expansion of the knowledge base essential for prevention efforts. Outcomes from trials built on such standards can serve to refine hypotheses and concepts related to risk and protective factors. The model building and hypothesis testing inherent in prevention research can elucidate pathways taken by individuals as they move toward or away from the onset of a mental disorder, as well as intervening mechanisms and brain-behavior-environment interactions that result in mental disorders or avert their occurrence, even in individuals at very high risk. In addition,

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH empirical validation of preventive interventions can usefully inform and broaden clinical practice. Epidemiological evidence, for example, can suggest causal factors that can best be tested in a preventive intervention research trial, which may, in turn, suggest molecular or behavioral mechanisms for further study. THE PREVENTIVE INTERVENTION RESEARCH CYCLE Just as the development of prevention into a science requires a series of rigorously designed research programs for its collective progress, so an individual research program requires a series of carefully planned and implemented steps for its success. Figure 10.1 presents the committee's concept of how these steps build upon another in the preventive intervention research cycle. The process proceeds in much the same sequence as it has in the report to this point. The first step is to identify and define operationally and reliably the mental disorder(s) or problem. The second step is to consider relevant information from the core biological and behavioral sciences and from research on the treatment of mental disorders, and to review risk and protective factors associated with the onset of the disorder(s) or problem, as well as prior physical and mental disorder prevention intervention research. The investigator then embarks on designing and testing the preventive intervention, by conducting rigorous pilot studies and confirmatory and replication trials (the third step) and extending the initial positive findings in large-scale field trials (the fourth step). If the trials are successful, the researcher facilitates the dissemination and adoption of the program into community service settings (the fifth step). Most of the research programs presented as illustrations in Chapter 7 are at the third step. Although the review processes that constitute the first and second steps in Figure 10.1 are considered to be part of the preventive intervention research cycle, the original studies in these areas, with the exception of the previous studies on the prevention of mental disorders or problems, are not. For the individual researcher, it is the activities in the third and fourth steps that constitute preventive intervention research per se. Likewise, it is not the community service program and its evaluation but the facilitation by the investigator of the program 's widespread dissemination and adoption (the fifth step) that is part of the research cycle. The knowledge exchange processes that operate between the researcher and the community at this step are discussed in more detail in Chapter 11. (In this report, the term community refers not just to a community as a whole, but also to an element within a community, such as a school, health care clinic, advocacy group, or neighborhood.)

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH The final steps in the cycle, represented by the feedback loop, are to review the results of any subsequent epidemiological studies to determine if the prevention program actually resulted in reductions in incidence of the targeted problem or disorder(s) and to respond to community representatives regarding their research interests and suggestions for further work. Each step in the cycle is outlined below. Sections later in the chapter present a host of issues relevant primarily to the research activities in steps three and four—including methodological issues pertaining to experimental design, sampling, measurement, and statistics and analysis, as well as documentation issues. Cultural, ethical, and economic issues that require attention throughout the cycle are also presented. In this discussion the terms preventive intervention program and preventive intervention trial are carefully delineated. The preventive intervention program is the activity or activities that are provided to the target population (e.g., home visitation with mothers and their infants or a substance use resistance training curriculum delivered to school children by their teacher). The preventive intervention trial is the research component designed with experimental protocols to evaluate and validate the success of the intervention program. Preventive intervention research program is the inclusive term for the program plus the trials. Identification of the Problem or Disorder(s) and Review of Information Concerning Its Extent The first step in the preventive intervention research cycle is to identify the disorder, cluster of disorders, or problem that is to be the target of the intervention. Knowledge regarding the diagnostic criteria and course of the disorder, as well as its incidence and prevalence, can be helpful in determining whether a preventive intervention for a particular disorder is warranted. Problems that are appropriate targets for intervention can include those such as child maltreatment that are serious social problems in their own right but are also risk factors associated with the onset of mental disorders. At this step in the research cycle, the investigator also considers the personal, social, and economic costs associated with the suffering and disability resulting from the problem or disorder. Further, because prevention research almost always touches the community in some way, even at its earliest stages, a partnership in project planning between the researcher and the community is highly desirable. Questions to ask at this point include: Is the particular problem or disorder a matter of concern within the social unit—

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH FIGURE 10.1 The preventive intervention research cycle. Preventive intervention research is represented in boxes three and four. Note that although information from many different fields in health research, represented in the first and second boxes, is necessary to the cycle depicted here, it is the review of this information, rather than the original studies, that is considered to be part of the preventive intervention research cycle. Likewise, for the fifth box, it is the facilitation by the investigator of the shift from research project to community service program with ongoing evaluation, rather than the service program itself, that is part of the preventive intervention research cycle. Although only one feedback loop is represented here, the exchange of knowledge among researchers and between researchers and community practitioners occurs throughout the cycle. The feedback loop demonstrates both the continuity of the cycle and the necessity to incorporate many different types of feedback into each step, including community responses, additions to the knowledge base, and ultimate effects of programs on incidence and prevalence of disorders. Cross-cutting issues regarding methodology, documentation, and cultural, ethical, and economic concerns are treated in the text.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH community, school, neighborhood, mental health service agency—where the research would be carried out? Would the community be responsive to the development of a research program to address such concerns? Giving the community a voice in defining the problem and in formulating the research program and procedures can be done in many ways, such as by having a representative from the community, perhaps a delegate from a service agency, participate with the research team on an ongoing basis (Kelly, Dassoff, Levin, Schreckengost, and Altman, 1988; Weiss, 1984; Snowden, Muñoz, and Kelley, 1979; see also the commissioned paper by Fawcett, Paine, Francisco, Richter, and Lewis, and commentaries by Gallimore and Rothman, available as indicated in Appendix D.) Review of Risk and Protective Factors and Relevant Information from the Knowledge Base Information regarding the concept of risk reduction and how it can be applied in research programs on the prevention of mental disorders can be obtained from a review of prevention programs in physical health (see Chapter 3). Knowing specifics about the predisposing biopsychosocial risk factors and environmental and personal protective factors that converge and interact to determine the onset of any mental disorder is critical for decisions that are made about the nature and targets of any preventive intervention strategy. To acquire this knowledge, the investigator can access a panoply of research disciplines, including molecular biology; behavioral, population, and molecular genetics; gene-environment interactions; neuroscience; developmental, experimental, and social psychology; sociology; behavior analysis; cognitive science; developmental psychopathology; and population and developmental epidemiology (see Chapter 4 and Chapter 5). The investigator next examines what is known regarding the relevant risk and protective factors affecting the onset of the disorder(s) or problem(s) of interest (see Chapter 6). This review provides information that will be useful later in choosing a theoretical model that specifies the mechanism or processes through which these factors have effects. In addition, the review can reveal information on sociodemographic or biological characteristics that may be helpful in targeting a population at risk, as well as identify modifiable risk or protective factors as potential targets for preventive intervention. A review of the relevant publications on prior preventive intervention research programs (see Chapter 7) is another essential step to take before designing the research program. Finally, some of the most important information about protective factors has come from research

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH on the treatment of mental disorders (see Chapter 8). Treatments to strengthen the social support network and social competence of an individual afflicted with a mental disorder, for example, have consistently been shown to improve that person's outcome. This points toward preventive interventions to reinforce these protective factors and thereby diminish the likelihood of stress-induced initial onset of illness. Pilot Studies and Confirmatory and Replication Trials Once the pertinent information has been reviewed, the investigator can begin the process of designing, conducting, and analyzing the research program. Initially, a small-scale, rigorously designed pilot study is done in a carefully controlled setting, often within a community institution, to test methods and procedures. A pilot study is exploratory in nature, and many alterations in design are made. Then the investigator applies the methods and procedures that appear to be successful to a larger population in a confirmatory trial to determine the efficacy of the research program, efficacy being “the extent to which a specific intervention, procedure, regimen, or service produces a beneficial result under ideal conditions” (Last, 1988). If a research program proposes to change risk or protective factors and does so, but the targeted factors are not causal, then the program will lack efficacy, failing to prevent the mental disorder even if it succeeds in altering the risk factor. Thus a well-controlled confirmatory trial can provide relevant data to confirm or deny the causal roles of hypothesized risk and protective factors. Finally, if the results from the confirmatory trial are encouraging, the same methods and procedures are applied in a replication trial to ensure continued efficacy. The Prenatal/ Early Infancy Project (Olds, Henderson, Tatelbaum, and Chamberlin, 1988, 1986), discussed in Chapter 7, is an example of a research program that is now being replicated in a new location. At this third step in the cycle, the investigator faces a number of decisions. The first of these is the choice of a theoretical model to guide the preventive intervention program. With this model in place, the form of the intervention program itself can be designed. The features of the program—including such things as intervention techniques and site—are chosen here, although they may be adjusted somewhat in step four, when the program is applied in a large-scale field trial. Intervention program design issues are distinct from the methodological issues involved in designing the research component of the program, a task that is encountered both in this step and in step four and thus is discussed as a cross-cutting issue later in this chapter. When the design work is done, the processes of recruiting and training interveners and

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH identifying and securing the cooperation of appropriate participants can begin. Then the studies or trials are conducted. Thorough documentation of all these choices and the reasons for them is essential to subsequent analysis, both in this step and in step four. This is discussed as a cross-cutting issue below. Choosing a Theoretical Model to Guide the Intervention Program To prevent the targeted disorder or problem, the investigator chooses a theoretical model based on the available body of knowledge that addresses one or more of the following factors: The presence of risk factors and absence of sufficient protective factors correlated with the disorder that may be both causal and malleable, that is, can be altered through intervention. The mechanisms that link the presence of risk factors and the absence of protective factors to the initial onset of symptoms (which may involve gene-environment interactions). The triggers that activate these mechanisms (including stressful life events, physical illness, and developmental changes). The processes that mediate the triggering event and the onset of symptoms. The processes that occur once symptoms have developed. Ideally, these processes can be attenuated through indicated preventive interventions before they cross the threshold criteria for diagnosis of the disorder. The choice of a theoretical model stems not only from formulations of risk and protective factors, mechanisms, triggers, and processes, but also from analysis of interventions. Whether a particular theoretical approach can guide prevention strategies depends on the data supporting it. Practically, most current evidence is limited to assessment of risk and protective factors, although there is considerable speculation regarding mechanisms and triggers. Therefore, for now, basing preventive interventions on the risk reduction model, that is, on theories involving the reduction of risk factors and/or enhancement of protective factors, is the most productive strategy. This may ultimately lead to studies on incidence of disorders. No matter which theoretical model is used, the ultimate goal of reducing the incidence of mental disorders is the same. Designing the Form of the Intervention Program The intervention program is made up of (1) the activity or activities that are provided to the targeted population, such as an educational

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH curriculum, supportive counseling, and child care, at a planned frequency and for a set amount of time; (2) the psychological, biobehavioral, educational, organizational, or social techniques and procedures —sometimes called change technologies—used; and (3) the site in which the intervention takes place. Theoretical and technological factors are closely intertwined and affect the choice of the intervention activities and change technologies. For example, educational interventions require teaching techniques known to work. Specific teaching techniques may work well with certain groups but not with others. If the instructors are not able to teach the participants the skills that are thought to decrease the probability of the disorder or problem, the theory cannot be tested, nor the intervention implemented. Interventions may thus have to be redesigned for different groups to address how they learn; language, educational level, cultural background, rural versus urban setting, and generational cohort will need to be considered. In addition to learning theory, intervention activities and change technologies may draw heavily on operations research, social psychology, behavioral modification technology, and a variety of other fields. They may include the use of biological-pharmacological, educational, or skills-building programs, environmental change strategies, new social policies, and regulations or laws. A variety of questions are typically addressed at this stage in the prevention research process, such as: Is this intervention acceptable and feasible for the targeted population? Has consideration been given to ethical concerns, cultural factors, and linguistic differences? Have issues of access been addressed, including potential barriers in the host institution or community and dissemination of information regarding the availability of the intervention? In addition, questions about intervention intensity (that is, the frequency and length of intervener-participant contacts), the feasibility of administering the intervention to a group instead of individuals, and the use of special technologies such as video tapes, computer-aided learning, and specialized medical techniques are addressed at this stage. Preventive interventions, in general, should be short enough to be practical, yet intensive and long-lasting enough to be effective. Obviously, it is best if they are not too costly, but the more relevant issue is whether the potential benefits justify the cost. With the possible exception of certain structural interventions, such as helping a participant secure a job, brief interventions usually cannot be expected to have long-term effects in preventing major disorders. Attempts to change behavior or instill certain skills and to sustain these changes over time require intensity of effort, not only from investigators, but also from participants.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Finally, it is useful to obtain information regarding how well the program and its component parts have been received. Feedback to the prevention researcher in this stage can come from the participants in the studies and trials as well as from community leaders (Krueger, 1988; Manoff, 1985). Recruiting and Training Interveners The choice of the interveners can be crucial to the success of the preventive intervention program. Sometimes the interveners are professionals; often they are not. Frequently, they have a natural relationship with the participant—such as being a teacher, parent, doctor, or neighbor (see Chapter 7). Careful selection, provision of initial training and ongoing supervision, payment of a salary, a reasonable workload, and involvement, as appropriate, with the interdisciplinary research team, help ensure high quality and low attrition of interveners. Identifying and Securing Cooperation from Appropriate Participants The researcher next decides for whom the intervention is appropriate. In general, the less expensive and the less likely to have any unintended adverse side effects the intervention is, the more widely it can be implemented (universal). As the intervention becomes more expensive, and as it becomes more potent, it becomes increasingly important for ethical as well as economic reasons to focus its implementation to reach the population most at risk (selective, then indicated). (See Chapter 2 for a discussion of population groups.) However, this is not to say that universal interventions are inexpensive to deliver. An intervention with even a low cost per participant becomes a large expense when delivered to thousands of participants. However, these delivery costs may be more than offset by the savings realized when disorders are prevented, especially if an entire lifetime of disability and expensive treatment can be avoided. One crucial element in identifying appropriate participants is the current understanding of the nature of the problem or disorder (reviewed in steps one and two of the research cycle), in part because individuals who already have the disorder in question must be excluded from the preventive intervention and individuals who are at especially high risk should be included. For most mental disorders, genetic predispositions have only a probabilistic influence on the manifestation of the illness. The onset of a disorder often depends on the nature of the interaction between genetic predisposition and

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH environment. Therefore, if genes related to mental disorders are eventually identified, individuals with these genes may be particularly appropriate participants in prevention trials for indicated interventions. Another crucial element is information about who in the population is at risk for the disorder or problem. This information comes not only from risk studies but also from treatment research (reviewed in step two). For example, a high incidence of a particular disorder within a population group identified by age, gender, or culture provides clues about whom to target. Finally, a knowledge of the developmental periods of risk and the ages of onset (from epidemiological studies reviewed in step two) is also valuable for decisions regarding when to intervene. The investigator next develops a plan to successfully engage the targeted participants. These participants, by definition, do not have a problem that they are necessarily motivated to cure or relieve. There is no way of ascertaining whether any one individual in an at-risk group will develop the disorder if the intervention is not received. Therefore potential participants may not be willing to participate. Influential members of the community can often help by providing access to the targeted group and gaining their cooperation. The investigator can then inform the potential participants not only about any risks involved, but also about how the intervention may be useful to them. Incentives for participation, such as payment for interviews, video tapes of children, printed educational materials, and free transportation, are often presented at this time. Noncompliance and attrition are major issues in prevention research programs. The intervention potentially can have its largest effects on participants who are receptive to its aims, participate in all intervention sessions, follow through on requests, and continue with the program until it is completed. But participants who do not comply may be those at the highest risk. Efforts to promote compliance are essential to well-designed interventions. One way to sustain participation is to shape the intervention so it is sensitive to the local culture and customs of the targeted group. For example, it is useful to uncover the targeted population's daily routine—including their daily tasks, their values and goals, and their culturally prescribed rules, norms, and scripts —as well as the motives, feelings, and meanings they may associate with the intervention (Gallimore, Goldenberg, and Weisner, in press; O'Donnell and Tharp, 1990). Making participation easy by crafting interventions congruent with these elements, and relevant to people 's lives, will increase participation.

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH project, yet nonetheless may be subjected to its indirect effects. Methods of recognizing and weighing the rights of these individuals are needed. Promote equity and justice. At a minimum, preventive interventions must not directly affirm or contribute to inequality or injustice. But a truly ethical approach must go beyond the minimum, to active promotion of equity and justice (Pope, 1990). As with the other ethical areas, there are no simple answers concerning how to enhance the general social well-being. Keeping this goal clearly in mind, however, will help ensure that ethical dilemmas are not ignored or discounted, and that researchers and institutions explicitly attend to them. To identify and attempt to resolve the various ethical issues destined to arise in preventive interventions, researchers will often be best served by joining with the members of the community—the providers of data and the targets of interventions (Trickett and Levin, 1990). As Conner (1990) has pointed out, ethical issues often involve trade-offs among competing sets of values that may or may not be shared between researchers and community members. He concludes that clients should play a central role in planning, implementing, and evaluating prevention programs. Rather than simply moving into a community and implementing large-scale prevention programs, researchers might announce their plans and then formally listen to the community's response—including the response from broader constituencies than the program's direct participants—before proceeding (Pope, 1990). In a prevention program for children, for example, Trickett and Levin (1990) note that parents might assume a variety of roles that could increase the sensitivity of researchers to potential ethical issues and provide a forum for their resolution. Also, involving administrators in the planning of a school intervention program may lead to a commitment for continuing the program beyond its externally funded demonstration phase—itself an ethical issue. Although there is consensus about the importance of ethics in prevention research on mental disorders, ethical accountability in this area has not yet received the emphasis it deserves. This remains a developing field, in need of increasing numbers of individuals and organizations possessing heightened sensitivity to ethical concerns and new skills for designing and conducting ethically appropriate intervention programs. Raising these ethical issues is not to suggest that initiation of preventive interventions should await unanimity on the goals and methods (Lorion, 1987). Rather, careful identification and analysis of these issues can be useful in broadening scientific perspective

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH and in increasing awareness of the potential range and impact of unintended consequences. ECONOMIC ISSUES The allocation of available resources to activities aimed at reducing the burden of mental problems in our society requires some capacity to estimate the benefits and costs of our efforts. Analysis of costs and benefits can help inform decision makers about which kinds of interventions for mental disorders hold the most promise for yielding net benefits. The basic goal is to reach a decision on whether a particular intervention program is worth undertaking or whether an existing program should be discontinued, expanded, or reduced in scope. Analysis of benefits and costs seeks systematically to identify and measure all the benefits and costs of a program (Muñoz and Ying, 1993). Obviously, if benefits exceed costs, then society profits from having the program available. On the other hand, if costs exceed benefits, a decision to allocate scarce resources to other purposes would seem warranted. There are two main methods for doing such an analysis. In cost-benefit analysis, costs and benefits are expressed in dollars. This process is adequate and straightforward for some measures, but it means that dollar amounts have to be assigned to all important outcomes. Assigning dollar amounts is difficult or nearly impossible for some measures, such as life and health. Cost-effectiveness analysis, on the other hand, avoids some of the above controversy by using two categories of outcome measures—dollars and health outcomes. Health outcomes can be presented, for example, in “years of healthy life gained.” The assumption is often made that preventive efforts are cost-effective. Some programs provide evidence that this may be true, but much more confirmation is desirable. The following useful framework is adapted from work by Russell (1986) for analyzing the cost-effectiveness of potential preventive efforts: Population and risk. The aggregate or net cost of an intervention depends on the size of the targeted population relative to the number of persons in the population who would be likely to develop the negative outcomes without the intervention. Even interventions that are relatively inexpensive per person may be quite costly in the aggregate if the target population is large and the number of persons in the population at risk is small. The more specific the definition of risk groups, the more likely the intervention will be cost-effective, other factors being equal. Cost and frequency of administration of the intervention. Preven-

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH tive interventions vary greatly in their cost. School curriculum innovations, for example, may be relatively inexpensive. Schools can replace ongoing programming with much more effective curricula at relatively little new cost in time or effort. On the other hand, intensive personal interventions using expensive professional personnel can be quite costly per person served. The cost of the intervention depends also on start-up costs, the size of the sample, and the required frequency of contacts with participants; as observed in Chapter 7, many preventive interventions require multiple contacts over an extended period of time. Thus the cost of an intervention is a product of its initial cost and the frequency of administration. Potency of the intervention. Interventions vary in the power of their effects. The efficiency of an intervention—as measured by the proportion of those at risk affected and the size of the effect—should be taken into account in evaluations of cost-effectiveness. Uncertainty of risk. For many problems and disorders the causal status of associated risk factors, and therefore the benefits from interventions targeted toward reducing those risk factors, remain uncertain, as do possible adverse events. When the risk of developing the disorder or problem is low and uncertain, thought must be given to the costs associated with exposing large populations to interventions that offer no advantages to most and possible adverse effects to some. Time. Another relevant consideration is the temporal proximity of the result of the intervention to its administration. Benefits are much greater for interventions that bring quick and persisting results than for those with delayed results or results that lessen over time. Once the preventive intervention moves into the community for the large-scale field trials, as well as on into the service realm, the costs and benefits may fall on different segments of society. The service agency or organization may be willing to share part of the cost. To the extent that a service agency assumes the cost for a preventive intervention, the cost-effectiveness of the intervention should be measured against the cost-effectiveness of other potential services. Alternatively, the preventive intervention may be carried as a public service announcement or administered by a community volunteer agency. Even though there may not be direct costs for the health sector or service agencies, these interventions would still entail costs in that they compete for alternative uses of the resources. Many potential preventive intervention research programs are consistent with the policy priorities for school districts, and the classroom and teacher resources required to conduct them could be achieved at

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH relatively low cost. On the other hand, if the program requires the hiring and training of a new cadre of mental health worker—or even the retraining of existing personnel—the costs of the program could be so great as to compromise its viability. The cost of prevention programs stems not only from the monetary cost of the intervention, but also from the potential costs involved for those receiving the service. This response cost or burden includes the participant's having to travel to a specific location, pay for travel or time lost for other activities, and undergo uncomfortable or time-consuming procedures, as well as the overall amount of effort involved in receiving the intervention. Perceived response cost may vary across sociocultural groups, even if monetary costs remain the same. For example, accepting “free” babysitting services while receiving a preventive intervention may be unacceptable to those cultural groups for whom sharing the childrearing responsibility is considered unwise or dangerous. Prevention programs should not be funded by withdrawing resources from needed, and usually underfunded, treatment services (see Chapter 2 for definitions). Even though preventive interventions may have a significant impact in terms of increased socialization and reduced psychopathology, cognitive impairment, and psychosocial dysfunction, they are unlikely to result in an immediate reduction in the need for treatment interventions. In part, this is because those currently being treated are a small proportion of those suffering from a disorder. Cost-benefit and cost-effectiveness analyses appear only infrequently in the treatment literature (Cardin, McGill, and Falloon, 1985; Weisbrod, Test, and Stein, 1980; Paul and Lentz, 1977) and are almost nonexistent in the prevention literature. As requests for these analyses increase over the next decade, there are several important points that policymakers and prevention researchers should consider (Gramlich, 1984). For example, benefits from prevention programs may increase over time. Short-term evaluations may show small or nonexistent benefits, but benefits may accrue as children are engaged over time in less crime, depend less on welfare, or begin to reap the benefits of higher levels of educational achievement. In addition, a well-designed and sensitive benefit-cost analysis can identify gainers and losers in society. Net social benefits may be received by participants in the program themselves, taxpayers, and potential victims of crime. Evaluation can show who gains and who loses as well as how big the overall gain or loss actually is. One example of a pioneering benefit-cost analysis of a prevention program is that done for the Perry Preschool Program, a selective preventive intervention (Berrueta-Clement, Schweinhart, Barnett, Epstein, and Weikart, 1984). (See Chapter 7 for a description of the

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH program.) The investigators documented the costs of high-quality preschool education and the benefits resulting from positive program outcomes. Results suggested that the total net benefit to preschool participants themselves was approximately $5,000. On the other hand, the total net benefit to taxpayers and potential crime victims was estimated at around $23,000 for one year of preschool by the time the program recipients reached 19 years of age. As the authors observed, “changes in economic success, self-sufficiency, and social responsibility can be predicted quantitatively from observed effects at age 19” (Berrueta-Clement et al., 1984, p. 89). Another example of a benefit-cost analysis of a preventive program is that done for the JOBS Project for the Unemployed, a selective preventive intervention aimed at helping the recently unemployed find new employment (Vinokur, van Ryn, Gramlich, and Price, 1991). (See Chapter 7.) Results from a 2½-year follow-up of participants in a randomized field experiment that included a jobs program aimed at increasing reemployment and preventing poor mental health outcomes showed the continued beneficial effects of the intervention on monthly earnings, quality of reemployment, and episodes of employer and job changes. Results of a benefit-cost analysis demonstrated large net benefits of the intervention not only to the participants, but also to federal and state governments, based on increased tax revenues produced by reemployed workers in the randomized trial. Not only did the benefits of the program exceed all costs within less than two years, but, because the wage differences appeared to persist, the benefits were expected to continue to accumulate over many years. According to the researchers' estimates, by the time experimental group participants reach age 60, they can be expected to have accrued $48,151 more benefit per person than their counterparts in the control groups, assuming they continue to be employed. CONCLUSION If the research standards and methodology outlined here are systematically and rigorously applied within the preventive intervention research cycle and the guidelines on cultural, ethical, and economic issues are carefully considered at each step, prevention research will yield progressively more powerful results over the next decade. The ensuing development of prevention into a science will provide a firm base of knowledge for policymakers. This knowledge will inform their decisions on the allocation of available resources toward the ultimate goal of realizing the opportunities presented by the science for the alleviation of

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH the personal and societal suffering and burdens associated with mental disorders. REFERENCES Alkin, M. C. ( 1985) A Guide for Evaluation Decision Makers. Beverly Hills, CA: Sage Publications. Barlow, D. H.; Hersen, M. ( 1973) Single-case experimental designs: Uses in applied clinical research . Archives of General Psychiatry; 29(3): 319–325. Berrueta-Clement, J. R.; Schweinhart, L. J.; Barnett, W. S.; Epstein, A. S.; Weikart, D. P. ( 1984) Changed Lives: The Effects of the Perry Preschool Program on Youths Through Age 19 (High/Scope Educational Research Foundation, Monograph 8). Ypsilanti, MI: High/Scope Press. Bestman, E. ( 1986) Cross-cultural approaches to service delivery to ethnic minorities: The Miami Model. In: M. Miranda and H. Kitano, Eds. Mental Health Research and Practice in Minority Communities: Development of Culturally Sensitive Training Programs. Rockville, MD: National Institute of Mental Health; DHHS Pub. No. (ADM) 86–1466: 199–226. Bliatout, B. T.; Rath, B.; Do, V. T.; Kham One, K.; Bliatout, H. Y.; Lee, D. T. ( 1985) Mental health and prevention activities targeted to Southeast Asian refugees. In: T. C. Owan, Ed. Southeast Asian Mental Health: Treatment, Prevention, Services, Training, and Research. Washington, DC: National Institute of Mental Health; DHHS Pub. No. (ADM) 85–1399: 183–207. Bloom, J. D.; Kinzie, J. D.; Manson, S. M. ( 1985) Halfway around the world to prison: Vietnamese in Oregon's criminal justice system. International Journal of Medicine and Law; 4: 563–572. Bolek, C. S.; Debro, J.; Trimble, J. E. ( 1992) Overview of selected federal efforts to encourage minority drug abuse research and researchers. Drugs and Society; 6(3/4): 345–375. Campbell, D. T. ( 1991) Methods for the experimenting society. Evaluation Practice; 12(3): 223–260. Cardin, V. A.; McGill, C. W.; Falloon, I. R. H. ( 1985) An economic analysis: Costs, benefits and effectiveness. In: I. R. H. Falloon, Ed. Family Management of Schizophrenia. Baltimore, MD: Johns Hopkins University Press; 115–123. CBASSE (Commission on Behavioral and Social Sciences and Education) . ( 1993) Understanding Child Abuse and Neglect. Panel on Research on Child Abuse and Neglect, National Research Council . Washington, DC: National Academy Press. Cohen, J. ( 1988) Statistical Power Analysis for the Behavioral Sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates. Conner, R. F. ( 1990) Ethical issues in evaluating the effectiveness of primary prevention programs. In: E. J. Trickett and G. B. Levin, Eds. Ethical Implications of Primary Prevention. New York, NY: The Haworth Press. Cook, T. D.; Campbell, D. T. ( 1979) Quasi-Experimentation: Design and Analysis Issues for Field Settings . Chicago, IL: Rand McNally. Cross, T. L.; Bazron, B. J.; Dennis, K. W.; Isaacs, M. R. ( 1989) Toward a Culturally Competent System of Care: Vol. I. Washington, DC: Georgetown University Child Development Center. DHHS (Department of Health and Human Services). ( 1991) National Institutes of Health.

OCR for page 359
REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Office for Protection from Research Risks. Code of Federal Regulations: Part 46—Protection of Human Subjects. Washington, DC: Government Printing Office. DHHS (Department of Health and Human Services). ( 1990) Breaking new ground for American Indian and Alaska Native youth at risk: Program summaries. Rockville, MD: Office for Substance Abuse Prevention; (OSAP Technical Report 3); DHHS Pub. No. (ADM) 90–1705. Dinges, N. G. ( 1982) Mental health promotion with Navajo families. In: S. M. Manson, Ed. New Directions in Prevention Among American Indian and Alaska Native Communities. Portland, OR: Oregon Health Sciences University; 119–143. Dressler, W. ( 1987) The stress process in a Southern black community: Implications for prevention research. Human Organization; 46: 211–220. Elandt-Johnson, R. C.; Johnson, N. L., Eds. ( 1980) Survival Models and Data Analysis. New York, NY: John Wiley and Sons. Fergusson, D. M.; Harwood, L. J.; Lloyd, M. ( 1991) Confirmatory factor models of attention deficit and conduct disorder . Journal of Child Psychology and Psychiatry; 32(2): 257–274. Galanti, G. ( 1991) Caring for Patients from Different Cultures. Philadelphia, PA: University of Pennsylvania Press. Gallagher, D.; Thompson, L. W. ( 1983) Cognitive therapy for depression in the elderly: A promising model for treatment and research. In: L. D. Breslau and M. R. Haug, Eds. Depression and Aging: Causes, Care, and Consequences. New York, NY: Springer Publishing Company. Gallimore, R.; Goldenberg, C. N.; Weisner, T. S. (in press) The social construction and subjective reality of activity settings: Implications for community psychology. American Journal of Community Psychology; 21. Gibbons, R. D.; Hedeker, D.; Elkin, I.; Waternaux, C.; Kraemer, H. C.; Greenhouse, J. B.; Shea, M. T.; Imber, S. D.; Sotosky, S. M.; Watkins, J. T. (in press) Some conceptual and statistical issues in analysis of longitudinal psychiatric data. Archives of General Psychiatry. Gilbert, J. ( 1990) Ethnographic research strategies in the cross-cultural substance use and abuse field. The International Journal of the Addictions; 25(2A): 123–148. Gramlich, E. M. ( 1984) Commentary on Changed Lives. In: J. R Barreuta-Clement, L. J. Schweinhart, W. S. Barnett, A. S. Epstein, and D. P. Weikart, Eds. Changed Lives: The Effects of the Perry Preschool Program on Use Through Age 19. Ypsilanti, MI: Monographs of the High Scope Educational Research Foundation; 8: 200–203. Hasenfeld, Y.; Furman, W. M. (in press) Intervention research as an interorganizational exchange. In: J. Rothman and E. J. Thomas, Eds. Intervention Research: Design and Development for Human Services. Binghamton, NY: The Haworth Press. Hiltz, S. R. ( 1974) Evaluating a pilot social service project for widows: A chronicle of research problems. Journal of Sociology and Social Welfare; 2(4): 217–224. Hood, P. D. ( 1990) How can studies of information consumers be used to improve the education communication system? Knowledge in Society; 3(2): 8–25. The Infant Health and Development Program. ( 1990) Enhancing the outcomes of low birth weight, premature infants: A multisite randomized trial. Journal of the American Medical Association; 263(22): 3035–3042. Issacs, M. R.; Benjamin, M. P. ( 1991) Toward a Culturally Competent System of Care: Vol. II. Washington, DC: Georgetown University Child Development Center. Jones, E. ( 1978) Effects of race on psychotherapy process and outcome: An exploratory investigation. Psychotherapy: Theory, Research, and Practice; 15: 226–236. Jones, E.; Matsumoto, D. ( 1982) Psychotherapy with the underserved: Recent develop

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REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH ments. In: L. Snowden, Ed. Reaching the Underserved: Mental Health Needs of Neglected Populations . Beverly Hills, CA: Sage Publications. Kavanagh, K. H.; Kennedy, P. H. ( 1992) Promoting Cultural Diversity: Strategies for Health Care Professionals . Newbury Park, CA: Sage Publications. Kelly, J. G.; Dassoff, N.; Levin, I.; Schreckengost, S. P.; Altman, B. E. ( 1988) A Guide to Conducting Prevention Research in a Community: First Steps . New York, NY: The Haworth Press. Kinzie, J. D.; Manson, S. M.; Do, T. V.; Nguyen, T. T.; Bui, A.; Than, N. P. ( 1982) Development and validation of a Vietnamese-language depression rating scale. American Journal of Psychiatry; 139(10): 1276–1281. Kleinman, A. ( 1988) The Illness Narratives. New York, NY: Basic Books. Kleinman, A. ( 1980) Patients and Healers in the Context of Culture. Berkeley, CA: University of California Press. Kraemer, H. C. ( 1979) Ramifications of a population model for kappa as a coefficient of reliability. Psychometrika; 44: 461–472. Krueger, R. A. ( 1988) Focus Groups: A Practical Guide for Applied Research. Newbury Park, CA: Sage Publications. Laird, N. M.; Ware, J. H. ( 1982) Random effects models for longitudinal data. Biometrics; 38: 963–974. Last, J. M. ( 1988) A Dictionary of Epidemiology. New York, NY: Oxford University Press. Le Xuan, K.; Bui, D. D. ( 1985) Southeast Asian mutual assistance associations: An approach for community development. In: T. C. Owan, Ed. Southeast Asian Mental Health: Treatment, Prevention, Services, Training, and Research. Rockville, MD: National Institute of Mental Health; DHHS Pub. No. (ADM) 85–1399: 209–224. Lefley, H. P. ( 1982) Cross-cultural training for mental health personnel. Final Report. Miami, FL: University of Miami School of Medicine; NIMH Training Grant No. 5-T24-MH15249. Levy, J. E.; Kunitz, S. J. ( 1987) A suicide prevention program for Hopi youth. Social Science and Medicine; 25(8): 931–940. Lewinsohn, P. M.; Clarke, G. N.; Hoberman, H. H. ( 1989) The Coping with Depression Course: Review and future directions. Canadian Journal of Behavioral Science; 21(4): 470–493. Liberman, R. P.; Eckman, T. ( 1981) Behavior therapy vs insight-oriented therapy for repeated suicide attempters. Archives of General Psychiatry; 38(10): 1126–1130. Locke, D. C. ( 1992) Increasing Multicultural Understanding: A Comprehensive Model. Newbury Park, CA: Sage Publications. Lorion, R. P. ( 1987) The other side of the coin: The potential for negative consequences of preventive interventions. In: Preventing Mental Disorders: A Research Perspective. National Institutes of Health. Washington, DC: DHHS Pub. No. (ADM) 87–1492. Lum, R. G. ( 1985) A community-based mental health service to Southeast Asian refugees . In: T. C. Owan, Ed. Southeast Asian Mental Health: Treatment, Prevention, Services, Training, and Research. Rockville, MD: National Institute of Mental Health; DHHS Pub. No. (ADM) 85–1399: 283–306. Maccoby, N.; Alexander, J. ( 1979) Reducing heart disease risk using the mass media: Comparing the effect on three communities. In: R. F. Muñoz, L. R. Snowden, and J. G. Kelly, Eds. Social and Psychological Research in Community Settings. San Francisco, CA: Jossey-Bass Publications. Manoff, R. K. ( 1985) Social Marketing: New Imperative for Public Health. New York, NY: Random House. Manson, S. M. ( 1993) Culture and depression: Discovering variations in the experience of

OCR for page 359
REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH illness. In: W. J. Lonner and R. S. Malpass, Eds. Psychology and Culture. Needham, MA: Allyn and Bacon. Manson, S. M. ( 1982) New Directions in Prevention Among American Indian and Alaska Native Communities. Portland. OR: Oregon Health Sciences University Foundation. Manson, S. M.; Brenneman, D. (in press) Chronic disease among older American Indians: Preventing depression and related problems of coping. In: D. Padgett, Ed. Handbook on Ethnicity, Aging, and Mental Health. Westport, CT: Greenwood Press. Manson, S. M.; Shore, J. H.; Bloom, J. D. ( 1985) The depressive experience in American Indian communities: A challenge for psychiatric theory and diagnosis. In: A. Kleinman and B. Good, Eds. Culture and Depression. Berkeley, CA: University of California Press; 331–368. Marin, G.; Marin, B. ( 1991) Research with Hispanic Populations. Beverly Hills, CA: Sage Publications. McCord, J. E. ( 1978) A thirty-year follow-up of treatment effects. American Psychologist; 33(3): 284–289. Montagne, M. ( 1988) The metaphorical nature of drugs and drug taking. Social Science and Medicine; 26(4): 417–424. Muñoz, R. F. ( 1993) The prevention of depression: Current research and practice. Applied and Preventive Psychology; 2: 21–33. Muñoz, R. F.; Chan, F.; Armas, R. ( 1986) Primary prevention: Cross-cultural perspectives. In: J. T. Barter and S. W. Talbott, Eds. Primary Prevention in Psychiatry: State of the Art. Washington, DC: American Psychiatric Press. Muñoz, R. F.; Ying, Y. W. ( 1993) The Prevention of Depression: Research and Practice. Baltimore, MD: Johns Hopkins University Press. Murase, K.; Egawa, J.; Tashima, N. ( 1985) Alternative mental health services models in Asian/Pacific communities . In: T. C. Owan, Ed. Southeast Asian Mental Health: Treatment, Prevention, Services, Training, and Research. Rockville, MD: National Institute of Mental Health; DHHS Pub. No. (ADM) 85–1399: 225–227. NAS (National Academy of Sciences). ( 1992) Responsible Science: Ensuring the Integrity of the Research Process . Washington, DC: National Academy Press. Neighbors, H. W. ( 1990) The prevention of psychopathology in African Americans: An epidemiologic perspective. Community Mental Health Journal; 26(2): 167–179. Neighbors, H. W.; Bashshur, R.; Price, R.; Selig, S.; Donabedian, A.; Shannon, G. ( 1992) Ethnic minority health service delivery: A review of the literature . Research in Community and Mental Health; 7: 55–71. Norton, I. M.; Manson, S. M. ( 1993) An association between domestic violence and depression among Southeast Asian refugee women. Journal of Nervous and Mental Disease; 180(11): 729–730. O'Donnell, C. R.; Tharp, R. G. ( 1990) Community intervention guided by theoretical development. In: A. S. Bellack, M. Hersen, and A. E. Kazdin, Eds. International Handbook of Behavior Modification and Therapy. 2nd ed. New York, NY: Plenum Press; 251–266. Olds, D. L.; Henderson, C. R.; Tatelbaum, R.; Chamberlin, R. ( 1988) Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. American Journal of Public Health; 78(11): 1436–1445. Olds, D. L.; Henderson, C. R.; Tatelbaum, R.; Chamberlin, R. ( 1986) Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics; 77(1): 16–28. Olweus, D. ( 1991) Bully/victim problems among schoolchildren: Basic facts and effects of

OCR for page 359
REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH an intervention program. In: K. Rubin and D. Pepler, Eds. The Development and Treatment of Childhood Aggression. Hillsdale, NJ: Lawrence Erlbaum Associates. Orlandi, M. A. ( 1992) Defining cultural competence: An organizing framework. In: M. A. Orlandi, Ed. Cultural Competence for Evaluators. Washington, DC: Office of Substance Abuse Prevention; DHHS Pub. No. (ADM) 92–1884. Page, J. B.; Chitwood, D. D.; Smith, P. C.; Kane, N.; McBride, D. C. ( 1990) Intravenous drug use and HIV infection in Miami. Medical Anthropology Quarterly; 4(1): 56–71. Paul, B. P. ( 1955) Health, Culture and Community: Case Studies of Public Reactions to Health Programs. New York, NY: Sage Publications. Paul, G. L.; Lentz, R. ( 1977) Psychosocial Treatment of Chronic Mental Patients. Cambridge, MA: Harvard University Press. Pope, K. S. ( 1990) Identifying and implementing ethical standards for primary prevention . In: E. J. Trickett and G. B. Levin, Eds. Ethical Issues of Primary Prevention. New York, NY: The Haworth Press. Rappaport, J.; Seidman, E.; Davidson, W. S. ( 1979) Demonstration research and manifest versus true adoption: The natural history of a research project to divert adolescents from the legal system. In: R. F. Muñoz, L. R. Snowden, and J. G. Kelly, Eds. Social and Psychological Research in Community Settings. San Francisco, CA: Jossey-Bass Publications; 101–144. Rossi, P. H. ( 1977) Boobytraps and pitfalls in evaluation of social actions programs. In: F. G. Caro, Ed. Readings in Evaluation Research. 2nd ed. New York, NY: Sage Publications. Russell, L. B. ( 1986) Is Prevention Better than Cure? Washington, DC: The Brookings Institution. Schilling, R. F.; Schinke, S. P.; Kirkham, M. A.; Meltzer, N. J.; Norelius, K. L. ( 1988) Social work research in social service agencies: Issues and guidelines . Journal of Social Service Research; 11(4): 75–87. Seitz, V. ( 1987) Outcome evaluation of family support programs: Research design alternatives to true experiments. In: S. L. Kagan, D. Powell, B. Weissbound, and E. Zigler, Eds. America's Family Support Programs: Perspectives and Prospects. New Haven, CT: Yale University Press. Shadish, W. R., Jr.; Cook, T. D.; Leviton, L. C. ( 1991) Foundation of Program Evaluation. Newbury Park, CA: Sage Publications. Sieber, J. ( 1993) Issues Presented by Mandatory Reporting Requirements. Paper commissioned by the CBASSE Panel on Child Abuse and Neglect, National Research Council. Washington, DC. Singer, M.; Flores, C.; Davison, L.; Burke, G.; Castillo, Z.; Scanlon, K.; Rivera, M. ( 1990) SIDA: The economic, social, and cultural context of AIDS among Latinos . Medical Anthropology Quarterly; 4(1): 72–114. Snowden, L. R.; Muñoz, R. F.; Kelly, J. G. ( 1979) The process of implementing community-based research. In: R. F. Muñoz, L. R. Snowden, and J. G. Kelly, Eds. Social and Psychological Research in Community Settings. San Francisco, CA: Jossey-Bass Publications; 14–29. Szapocznik, J.; Kurtine, W. M. ( 1993) Family psychology and cultural diversity. American Psychologist; 48(4): 400–407. Tharp, R. G.; Gallimore, R. ( 1988) Rousing Minds to Life: Teaching, Learning, and Schooling in Social Context. Cambridge, MA: Cambridge University Press. Thurman, P. J.; Jones-Saumty, D.; Parsons, O. A. ( 1990) Locus of control and drinking behavior in American Indian alcoholics and non-alcoholics. American Indian and Alaska Native Mental Health Research; 4(1): 31–39.

OCR for page 359
REDUCING RISKS FOR Mental Disorders: FRONTIERS FOR PREVENTIVE INTERVENTION RESEARCH Trickett, E. J.; Levin, G.B. ( 1990) Paradigms for Prevention: Providing a Context for Confronting Ethical Issues. New York, NY: The Haworth Press. Trotter, R. T., II; Rolf, J.; Quintero, G. A.; Alexander, C.; Baldwin, I. (in press) Cultural models of drug abuse and AIDS on the Navajo Reservation: Navajo youth at risk. Medical Anthropology Quarterly. True, R. H. ( 1985) An Indochinese mental health service model in San Francisco. In: T. C. Owan, Ed. Southeast Asian Mental Health: Treatment, Prevention, Services, Training, and Research. Rockville, MD: National Institute of Mental Health; DHHS Pub. No. (ADM) 85–1399: 329–342. U.S. Census Bureau. ( 1990) Census of Population. Unpublished tabulations. Vega, W. A. ( 1992) Theoretical and pragmatic implications of cultural diversity for community research. American Journal of Community Psychology; 20(3): 375–391. Vega, W. A.; Murphy, J. ( 1990) Projecto Bienestar: An example of a community-based intervention. In: W. A. Vega and J. W. Murphy, Eds. Culture and the Restructuring of Community Mental Health. Westport, CT: Greenwood Press; 103–122. Vega, W. A.; Valle, R.; Kolody, B. (submitted for publication) Preventing depression in the Hispanic community: An outcome evaluation of Projecto Bienestar. Vega, W. A.; Valle, R.; Kolody, B.; Hough, R. ( 1987) The Hispanic social network prevention intervention study: A community-based randomized trial. In: R. Muñoz, Ed. Depression Prevention: Research Directions. Washington, DC: Hemisphere Publishing. Vinokur, A.D.; van Ryn, M.; Gramlich, E. M.; Price, R. ( 1991) Long-term follow-up and benefit-cost analysis of the Jobs Program: A preventive intervention for the unemployed. Journal of Applied Psychology; 76(2): 213–219. Walker, P. S.; Walker, R. D.; Kivlahan, D. ( 1988) Alcoholism, alcohol abuse, and health in American Indians and Alaska Natives. In: S. M. Manson and N. G. Dinges, Eds. Behavioral Health Issues Among American Indians and Alaska Natives: Explorations on the Frontiers of the Biobehavioral Sciences. Denver, CO: University of Colorado Health Sciences Center. Weisbrod, B. A.; Test, M. A.; Stein, L. I. ( 1980) Alternative to mental hospital treatment: III. Economic benefit-cost analysis. Archives of General Psychiatry; 37: 400–405. Weiss, C. H. ( 1984) Increasing the likelihood of influencing decisions. In: L. Rutman, Ed. Evaluation Research Methods: A Basic Guide. Beverly Hills, CA: Sage Publications: 159–190. Weithorn, L. A. ( 1987) Informed consent for prevention research involving children: Legal and ethical issues. In: Preventing Mental Disorders: A Research Perspective. Washington, DC: National Institute of Mental Health. DHHS Pub. No. (ADM) 87–1492. Wellin, E. ( 1955) Water boiling in a Peruvian town. In: B. P. Paul, Ed. Health, Culture and Community. New York, NY: Russell Sage Foundation; 71–103.