Over the past 7 years, the Applied Prevention Sciences International (APSI) team has been developing a model for planning and implementing evidence-based prevention programming at the community level indicated in the graphic within the black circle. We started by borrowing a model developed by the European Monitoring Center(1) which laid out the primary steps in the model which we adapted to the four primary boxes listed in purple. Most planning and implementation models include these actions as prevention professionals and their community partners work on planning to address emerging problems. We then see the monitoring and evaluation boxes which contribute data during all four planning stages--defining the problem, documenting activities and services, providing short-term outcomes, and sustaining the program. These data feed directly into improvements to the intervention, its delivery, and other aspects of the programming, while informing the decision-making in regard to sustaining the intervention beyond the initial implementation time-frame. In addition, the sustainability phase engages stakeholders in reviewing and assessing “what happened” and whether the project should be continued.
What’s new. What we have added to the model recently are the four boxes indicated in the left in the graphic that should guide the programmatic action steps—cultural competence; ethics, and social justice, that contribute to equity—a goal for all evidence-based prevention programming to reach all populations in need. So, let’s start by looking at these first out-of-the-box actions as we consider plans for our work.
Equity. As the goal for our programming, we need to understand some basic concepts of equity. Merriam-Webster defines the social use of the term as “justice according to natural law or right, specifically : freedom from bias or favoritism.” Dictionary.com says “the quality of being fair or impartial; fairness; impartiality: the equity of Solomon; something that is fair and just.” But currently its use in the arena of health, particularly, is a goal to overcome long-term disparities that interfere with the potential of providing equality in services. So, in many ways, equity is more than equality. It involves whatever it takes to address the specific barriers and other potential difficulties in reaching at-risk populations with the high quality of services needed. So, we can look at some of the elements that feed into our ability to provide equity in services.
Ethics. The Prevention Think Tank Principles(2) listed here constitute six guides for behavior for prevention professionals and they help to pinpoint how these can help build equity as we plan our prevention programming.
Non-discrimination clearly means providing fair and equitable access and services; competence, integrity, nature of services and confidentiality all contribute to the quality of programming; while ethical obligations for community and society really meet the definition of equity itself.
Social Justice. However, these ethics standing alone, do not assure equity. Social justice provides a value-based framework within which we can operationalize our code of ethics. What is Social Justice? The Society for Prevention Research defines social justice as “… the ethical and moral imperative to understand why certain population subgroups have a disproportionate burden of disease, disability, and death, and to design and implement prevention programs and systems and policy changes to address the root causes of inequities.” It serves to enhance the well-being of individuals through equal access to healthcare, justice and economic opportunity.
Cultural Competence. While social justice provides the values that underscore equity, how can we best reach them with evidence-based prevention? The Centers for Disease Control and Prevention states the definition above and the following principles which can guide our work with cultural competence:
Define culture broadly.
Value clients' cultural beliefs.
Recognize complexity in language interpretation.
Facilitate learning between providers and communities.
Involve the community in defining and addressing service needs.
Collaborate with other agencies.
Professionalize staff hiring and training.
Institutionalize cultural competence.
An Integrated Implementation Model. How do we put this all together? The graphic presented above shows that to achieve equity we need to apply social justice values, cultural competence principles, and ethical conduct and practice to assure inclusiveness throughout the implementation cycle, as in the following:
From identifying vulnerable populations and the availability of resources for reaching them,
Engaging representatives of the target population in:
- Selecting potential evidence-based interventions or policies (EBI) to best serve population needs,
- Developing and testing processes to determine ‘fit’ of EBIs with existing values, beliefs, language for adaptations without losing fidelity to core of the intervention,
- Piloting the delivery of the adapted intervention to determine receptivity, and attainment of short-term EBI outcomes, and
- Reviewing the findings to decide on the continuation and ‘scaling out’ of the intervention to the full target population.
If decided to fully implement the adapted intervention, start recruiting and training prevention professionals to deliver the intervention and to recruit participants,
Monitor the fidelity of implementation of delivery and assess short-term and if possible, evaluate intermediate and long-term outcomes,
Review the results of the monitoring process with representatives of the targeted population and make decisions regarding continuing and sustaining the intervention.
The current COVID-19 pandemic has accentuated health disparities where overwhelmingly African-American, Latinx, and Native American communities have been hardest hit in terms of morbidity and mortality. During the rollout of the vaccinations, it became apparent that the vaccine distribution strategies(3) were not being effective in reaching these populations. So, to address this, public health planners are currently in the process of revising their distribution plans to address these disparities.(4)
So, as we begin the process of planning and implementing prevention services, we must address these foundational elements, cultural competence, ethics, social justice and equity, which are essential to providing the highest quality of evidence-based programming to reach our targeted populations. This may involve overcoming the barriers and other disparities that may interfere with program success. Then throughout our planning, these concepts need to stay front and center as we progress through the implementation process and all the way through as we monitor and evaluate what we are doing. At every stage, collaborating with community partners will help to produce and deliver the most effective programming.
European Drug Prevention Quality Standards, European Monitoring Centre for Drugs and Drug Addiction, 2010.
Prevention Think Tank Code of Ethics: https://www.internationalcredentialing.org/Resources/Documents/Prevention%20Think%20Tank%20Code%20of%20Ethical%20Conduct.pdf