Prevention

Risk and Prevention

Risk refers to a probability linking a “risk factor” such as poor academic skills with an outcome such as dropping out of school. Risk does not describe a causal relation, although a risk factor may be part of an etiological process. If in a given school 85% of 3rd graders with test scores below the 25th percentile drop out before 12th grade, the 25th percentile could be used as a cut score for distinguishing a group of 3rd graders with a high probability (high risk) of dropping out. Risk status is ideally linked with delivery of interventions. In a preventive-oriented service delivery system, resources are deployed at various stages prior to the time at which problem outcomes are expected to appear. Implementation of interventions—for example, smaller class size and intensive instruction in reading, mathematics, and content knowledge for children whose grades on standardized test scores fall below the 25th percentile—might lead to only 15% of children who score below the 25th percentile dropping out.

Primary prevention is aimed at the entire population, without regard to risk status, and is delivered before the causal process thought to underlie the problem outcome begins, for example, inoculating all children for certain diseases. The aim of primary prevention is to eliminate the problem outcome in the population. Secondary prevention actions are delivered to a particular group—a high-risk group—whose probability of attaining the problem outcome is elevated. The link between high-risk status and secondary prevention enables the action to be targeted more narrowly than for primary prevention efforts. Prekindergarten programs for poor four-year-old children are examples of secondary prevention. Secondary prevention actions are delivered before the problem outcome is incurred by the group members and are evaluated in terms of how they lower the risk coefficient for the target group. Tertiary prevention actions are delivered after a problem outcome has occurred. These actions basically involve remediation of the effects of a problem outcome and are offered only to individuals who have incurred problem outcome status. Special education or programs for children with certain disorders or disabilities are examples of tertiary prevention efforts. In actuality, the distinctions between these services are blurred; however, services are more preventively oriented when they are delivered early, on a widespread basis and in the absence of having clearly attained problem outcome status.

Cowen (1999) points out a fourth form of intervention, competence enhancement. Prevention approaches have as their goal the elimination of pathology, such as reducing reading failure, whereas competence enhancement focuses on improving positive outcomes for all children. Traditional prevention approaches are biased by a focus on negative outcomes. In Cowen's view, this focus could reduce efforts to promote health in the population. For example, in dental health, a focus on eliminating cavities and tooth decay led to the widespread use of fluoride. But tooth decay still increased in children who did not brush their teeth or receive regular teeth cleaning. The focus on preventing negative outcomes neglected the larger needs to promote dental health. Clearly, prevention and health promotion are not the same.

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