This morning’s opening plenary session focused on the new Affordable Care Act which has come into force in the United States, and its impacts and challenges for the health care system in the US. It’s interesting to listen to the talks as an outsider, and just how much the health and social care system here differs from the one which I’m familiar with in the UK. The Presidential Address by Dr Howard Koh, Assistant Secretary of the US Department of Health and Human Services really impressed me, particularly the clear vision he set out, and his emphasis upon the need to link health and non health agencies if we are really to address the social determinants of health.
Some key themes ran through the four papers which formed the opening plenary – the heightened role which the Affordable Care Act gives to prevention in general, the greater quality or care and the access to it, and the need for different agencies and sectors to work together. Systems and structures matter. Dr Koh’s talk suggested that around 9 million Americans had moved from having no health insurance to having some insurance, and how the this and the changes in restrictions on upper limits of care provision, had addressed the problem of ‘medical bankruptcy’ – not a term that I’ve heard used in discussions of the UK health system.
Special Interest Group (SIG) Meeting: Implementation and Adaptation in Prevention Research
This was a really good discussion, which tried to identify key issues which the science of implementation needs to address. It seemed to me that a key theme running through much of the conference sessions I attended today were concerned with fidelity and adaptation, as well as the development of implementation systems.
Some of the key issues which were discussed in this SIG meeting were:
· How important are fidelity and adaptation, and how do these two concepts interrelate – for instance, adaptations can enhance fidelity, as well as reduce it
· Does quality of implementation matter as well as, or even more than, fidelity of implementation (the ‘how’ as well as the ‘what’)?
· How do you ‘go to scale’ with interventions, and is more helpful to conceptualise this question as ‘how to you build intervention sustainability?’?
· What kinds of adaptations do people make?
Implementing Prevention Programs, Policies, And Practices: Context, Culture and Fidelity
Three really interesting papers, and some good points about fidelity and context. Jose Ruben Parra-Cordanna described her team’s contribution to moving the debate about adaptation forward, from ‘whether we should adapt’ to ‘how can we adapt’, and talked about their adaptation of a parenting programme for Latino immigrants – the very high rates of father engagement seemed impressive – at about 85% of those approached I think.
Joy Lanwehr’s talk looked at a programme comprising visits by mentors to schools, and the important role played by school and district context in supporting or in some cases undermining the intervention. For instance, how class teachers interacted with the mentor during their visits could be highly influential.
Finally Phillip Graham raised some important questions about the implementation of evidence-based interventions in urban, culturally diverse areas. Some of the key questions I noted were:
· How do we know when an intervention needs updating (either because out theories change, or because the problems or contexts we’re studying change)
· The importance of understanding how an intervention is designed to be delivered, and the intended mechanisms of change, and not only whether the programme manual is followed to ‘the letter’ or the language/terms changed/kept the same.
21st Century Family-Based Prevention: Connecting Theory to Etiology, To Intervention Content
Mark Van Ryzin presented results from a meta analysis of family-based prevention programmes. He noted that
· there are now many efficacious programmes, which are becoming more diverse over time
· that the move to use web based interventions is an important trend, as is the adaptation of existing interventions
· there is increasing attention being paid to fidelity, including the use of manuals and manualisation.
The paper presented the results of the meta-analyses which code programme components (e.g. content on behaviour management, affective relationships, etc), but there did not appear to be any main effects according to these components. One of the questions at the end asked about whether it would be helpful to look at styles/methods of delivery, which seemed a useful point.
Nancy Gonzales described her work around engaging families in school-based programmes, and the difficulties of achieving this. She asked whether an effective programme that is long can be sustained, and described her team’s work in determining how interventions could be ‘streamlined’ and shortened, whilst retaining the core components and mechanisms. Self-regulation was identified as the basis of the intervention being discussed, which allowed decisions to be made about what needed to be kept. She made the point that ‘hardened’ manuals don’t necessarily fit with current day demands on parents’ time, and linked this to the rise of social media.
Finally, Gene Brody gave a fascinating talk about the potential of parenting/family programmes to reduce the risk of physical health problems (such as cardiovascular disease). The theory underlying this was that high quality parenting can buffer the health effects in adulthood of having grown up in a low SES area. That is, that family-centred interventions can ameliorate social and ethnic inequalities in health.
Following the three paper, Thomas Dishon provide a summary and discussion of the three papers. Some key points which I noted were:
· The important role of NIDA funding in family-based prevention work
· Levels of engagement at the outset of a trial affect how we interpret the results down the line (e.g. from 5% of the families that were originally engaged?)
· The value of moving from thinking about programs to thinking about principles – we need to integrate evidence-based principles into the everyday work of agencies. We need to think about systems, and how the service setting affects our ability to deliver effective interventions.
· That it is becoming harder to engage parents in interventions due to time constraints, etc.
Parenting Factors and the Prevention of Unhealthy Outcomes among Youth
Melissa Lippold’s paper examined the links between parental knowledge of youth activities and its association with substance use. Her research focus on whether lability (fluctuations) in knowledge could have links to problem behaviour – through processes linked to unclear standards; impacts on self esteem, depression, and internalisation of norms. The findings of the research were pretty striking – variation in knowledge was mainly explained by lability (85%) compared to expected developmental trends (15%). Lability appeared to be associated with substance use, with some moderation with gender (greater associations between lability and delinquency and internaliazing problems for girls). She discussed the possible explanations for these results, reflecting that it may be normative for families to experience ‘ups and downs’ in knowledge from year to year, and may reflect the renegotiation of relationships as young people enter adolescence. The influences on these processes could be either parent or child driven.
Stephanie Ayers used an ecodevelopmental model to look at the relationships between family, peer, school and neighbourhood factors and rates of substance use among American Indian Youth. There were some interesting relationships here – while family communication as a whole didn’t appear to differ across users/non users of alcohol and other substances, for specific aspects of parenting such as rule and norm setting (I think) there were some quite strong associations.
Finally Dexter Thomas looked at whether parent-child relationships mediated the association between family low income and worse diabetic outcomes (for young people with Type 1 diabetes, which is not caused by diet/lifestyle factors). This association was based on the economic stress which low socio-economic status could create on parenting styles, and the fact that parents with greater resources may invest more in their children. The analysis found that lower income was indirectly associated with poorer adherence to diabetes reigimens, and that poorer adherence and gylcemic control was influenced by parenting constructs.