SCALING-UP EVIDENCE-BASED INTERVENTIONS IN US PUBLIC SYSTEMS TO PREVENT BEHAVIORAL HEALTH PROBLEMS: CHALLENGES AND OPPORTUNITIES
In 2016, SPR formed the Mapping Advances in Prevention Science (MAPS) IV Translation Research Task Force to build on and extend the MAPS II Translation Research Task Force efforts. This paper summarizes the MAPS IV Task Force findings regarding factors influencing and facilitating the uptake of EBIs after they have demonstrated effectiveness in rigorous evaluations. Whereas the MAPS II Task Force considered how prevention researchers could advance EBI implementation and dissemination, the MAPS IV Task Force was more outward-focused and examined how EBIs could be scaled up within public systems, specifically the behavioral health, child welfare, education, juvenile justice, and public health systems.
Fagan, A.A., Bumbarger, B.K., Barth, R.P. et al. Scaling up Evidence-Based Interventions in US Public Systems to Prevent Behavioral Health Problems: Challenges and Opportunities. Prev Sci 20, 1147–1168 (2019). https://doi.org/10.1007/s11121-019-01048-8
Scaling-up Evidence-based Interventions in U.S. Public Systems
Prepared by SPR MAPS (Mapping Advances in Prevention Science) IV Translation Research Task Force
These policy briefs were prepared by the SPR MAPS* (Mapping Advances in Prevention Science) IV Translation Research Task Force, which was charged by SPR to consider ways to significantly scale-up evidence-based interventions (EBIs) that have been shown to improve public health and well-being. The briefs highlight factors influencing EBI scale-up in three public systems: behavioral health, education, and public health. They also provide recommendations for actions that can help facilitate EBI scale-up, including: (1) increasing public policies and funding to support the creation, testing, and scaling-up of EBIs; (2) developing and evaluating specific frameworks to foster EBI scale-up and address systems-level barriers; and (3) promoting public support for EBIs, community capacity to implement EBIs at scale, and partnerships between community stakeholders, policy makers, practitioners, and scientists. The findings in these briefs and two additional public systems, child welfare and juvenile justice, will be described more fully in a forthcoming article to be published in Prevention Science.
Behavioral health disorders, such as depression and substance abuse, are now the leading cause of disease and death in the U.S. Although we know how to prevent behavioral health problems, effective prevention programs still do not reach the majority of Americans. Former Surgeon General David Satcher described this gap–between what we know about how to prevent these problems, and what we do to prevent these problems— as “lethal to Americans.” To eliminate this gap, we must scale-up effective behavioral health prevention programs to youth, families, and communities across the United States.
The Behavioral Health System is Already Positioned to Support Prevention Programs
In 2016, nearly one out of every four adults suffered a mental and/or substance use disorder, and the consequences of these disorders affect their families, communities, and society at large. In 2013, over 85,000 people died by suicide or overdose, with opioid abuse a major contributing cause: Deaths from synthetic opioids increased 1000 percent from 2011 to 2016. The economic burden of suicidal behaviors and opioid abuse is tremendous and was estimated to be in excess of $136 billion in 2013.
The true tragedy, however, is that while we know how to prevent these harmful and costly disorders from occurring, we have yet to dedicate the necessary resources to do so. The good news is that the behavior health system already has the basic infrastructure at the state level needed to support and scale up prevention programs. The Substance Abuse and Mental Health Services Administration (SAMHSA) currently provides statutory and monetary support to every state for the prevention of substance abuse and mental illness.
Most of this work is currently funded through two federal block grants administered by SAMHSA: the Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant. These are non-competitive grants mandated by Congress to go to states, assuming they meet their statutory and regulation requirements.
With the passage of the Every Student Succeeds Act (ESSA), schools must not only improve students’ academic performance, but also create positive school climates, reduce bullying and other problem behaviors, and provide alternatives to discipline practices that remove children from the school. This daunting mandate recognizes that schools are well positioned to help all youth succeed. Compared to other public agencies, the education system is better equipped to provide supports to all children (and their families) regardless of their race/ethnicity, gender, income level, and disability status. Schools can also track individual students over time and ensure that those who are struggling receive assistance.
Educators know that schools should do more than just focus on academics Schools must also educate and promote the health and well-being of “the whole child.” School administrators and staff invest significant resources each year to promote student education, safety, health, and well-being. To address these needs, schools require additional resources and supports; without them, problems like bullying, harassment, and school shootings will continue.
As described in this brief, schools can enhance their efforts to prevent these problems and to help students succeed by implementing evidence-based programs and practices (EBPs). Dozens of EBPs have been created and tested. They have been shown to improve students’ academic performance and graduation rates, foster positive school climates, develop children’s social-emotional learning skills, improve children’s health, increase student safety, and reduce bullying. These EBPs are available and provide all the supports that schools need to implement them. To guide schools in using EBPs, this brief provides a roadmap for how schools can capitalize on these resources to enhance students’ well-being, and offers recommendations for how schools can address barriers that may impede their use of EBPs.
Although the United States spends almost three trillion dollars on the delivery of health care, the country has a lower life expectancy and more uninsured people than many of the other industrialized nations. Of the dollars expended on health care, a small percentage is spent on primary prevention. Since health care contributes only a small portion (10%) of the overall health of a population, improvements in the health and well-being of the population require behavior changes and supports in social and physical environments. In addition, investments in social determinants of health—e.g., going “upstream” to prevent disease and illness—are cost-effective, save lives, promote health equity, and increase productivity.
Evidence-based Solutions Exist to Promote Health and Well-being
The research base documenting the effectiveness of public health programs and policies for improving population health is large and growing. Public health has a number of databases (e.g., Health Impact in 5 Years [HI-5], Guide to Community Preventive Services, County Health Rankings and Roadmaps, Results First Clearinghouse Database) which list over a thousand evidence-based programs, policies and strategies to improve health. A recent report of the Trust for America’s Health recommends evidence-based policies that promote health, control costs, and reduce health inequities in states by addressing social determinants of health related to education, healthy behaviors, housing, safety and employment.
Despite this extensive body of research on evidence-based programs and policies that have been shown to improve health and well-being, many are not being implemented at scale in public health and other systems. In fact, there have been large time lapses between the documentation of threats to health outcomes and the implementation of programs and policies to address the threats. For example, over 25 years elapsed from the release of the Surgeon General’s Report on Smoking and Health in 1964 to the development of the first tobacco control programs in Massachusetts and California. The recommendations of other Surgeon General reports on a variety of topics (e.g., obesity, addiction, mental health, oral health, youth violence, physical activity, nutrition) have not been implemented at scale in states or nationally.
*The SPR MAPS (Mapping Advances in Prevention Science) are charged by the SPR Board of Directors with advancing an emergent focal area for prevention science. This work was supported by the National Institute On Drug Abuse of the National Institutes of Health (NIH, R13DA033149), with co-funding from the NIH Office of Behavioral and Social Sciences Research, Office of Disease Prevention, Office of Research on Women’s Health, National Cancer Institute, National Center for Complementary and Integrative Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute on Alcohol Abuse and Alcoholism, and the Administration for Children and Families and the Centers for Disease Control and Prevention. The content is solely the responsibility of the MAPS IV Task Force members and does not necessarily represent the official views of the National Institutes of Health.