948786 research-article2020 PRVXXX10.1177/2632077020948786Journal of Prevention and Health PromotionHerman et al. Article Journal of Prevention and Prevention Science Health Promotion 2020, Vol. 1(1) 131 –151 as a Platform for © The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions Solving Major Societal httpDs:O//dIo: i1.o0r.g1/1107.171/2776/322630270770720020994488778866 journals.sagepub.com/home/prv Problems and Improving Population Health Keith C. Herman1 , Wendy M. Reinke1, and Aaron M. Thompson1 Abstract The article describes a prevention science approach to impacting population health. We use activities of the Missouri Prevention Science Institute that address youth mental health concerns with a public health approach to illustrate the approach. In particular, we focus on several lessons that may be relevant for advancing the success of prevention and health promotion scholars in addressing major societal problems: connecting small ideas to big solutions, matching intervention targets with goals, developing reliable and systemic monitoring data streams, ensuring data and prevention efforts account for cultural context, and helping people/systems change. Keywords youth mental health, prevention science, Missouri Prevention Science Institute 1Missouri Prevention Science Institute, University of Missouri, Columbia, MO, USA Corresponding Author: Keith C. Herman, Missouri Prevention Science Institute, University of Missouri, 16 Hill Hall, Columbia, MO 65211, USA. Email: [email protected] 132 Journal of Prevention and Health Promotion 1(1) For over a decade, the Missouri Prevention Science Institute (MPSI; for- merly, the Missouri Prevention Center) has served as the hub for our research and practice efforts. From its humble beginnings in 2007 as a volunteer effort of graduate students and faculty (described in three prior publications; Herman et al., 2010, 2019; Reinke et al., 2010), MPSI is now a major research, practice, training, and policy enterprise. MPSI faculty have garnered more than US$50 million of funding to support our work within the past decade, 80% as federal research grants and the remaining as local service-oriented contracts. We have more than 70 employees who are funded in whole or part by MPSI grants including graduate students (≈15), faculty members (≈10), and full- (≈30), and part-time staff (≈20). In addition, we host year-round academic courses, provide clinical training in prevention practices, and deliver community outreach and consultation related to parenting, classroom management, and school climate. Most recently, with funding and support from our local government, MPSI started two innovative initiatives to support youth mental health in local schools (Boone County Schools Mental Health Coalition [the Coalition]) and a community clinic that serves youth using a family systems model (Family Access Center of Excellence [FACE]). MPSI is the umbrella organization that houses and administers these programs and services. That is, (a) MPSI faculty developed and manage the Coalition and FACE, (b) MPSI fiscal and pre-award staff help administer the Coalition and FACE’s human resources and payroll, and (c) Coalition and FACE staff are MPSI employees. These are countywide efforts to improve the social and emotional well-being of all youth in our county and to reduce disproportional juvenile detention and school discipline practices experienced by youth of color. The Coalition is a partnership among all six county school districts and several parochial schools, encompassing 54 K–12 school buildings (Thompson et al., in press). The Coalition uses a tiered prevention model where we screen all K–12 youth (~25,000 students) in county schools 3 times per year for social and emotional risk factors (e.g., poor social or coping skills, exposure to bullying, problems with attention, disruptive behaviors). Youth identified by the data to be at higher levels of risk are then provided with additional assessments and supports that target those risk factors. Using the screening and assessment data, our team provides technical assistance to all 54 county schools to select and monitor the impact of scientifically based supports. In the 2018–2019 school year, as a result of the checklist data approximately 5,900 youth received an intervention to support their social behavioral or emotional health. FACE is a sister program to the Coalition and is intended as a school- community linked program to improve access to care for high-risk youth and Herman et al. 133 their families. Opened in 2016, FACE is a free service where any family with concerns about a child can access a brief evaluation, motivational interven- tion, and referral to community providers. Families can be referred by other service providers or they can self-refer and access services by making an appointment via an online portal, phone call, or walk-in. Once linked to exist- ing services, FACE provides nonconflicted case management services for families with higher needs. By nonconflicted, we mean that families are free to choose the services they wish to pursue and that FACE has no economic conflict of interest in supporting whatever choices the family makes (e.g., referrals are always to external agencies, not to subagencies connected with FACE). In addition, we work with community providers to improve the qual- ity of care by incentivizing evidence-based practices and providing ongoing training, coaching, and feedback about quality of services provided. In the first 6 months after opening, FACE served more than 300 families; 3 months later, we doubled that total. All of our work through FACE, the Coalition, and MPSI has focused on building a comprehensive, community, and school approach to address youth mental health concerns. As we reflect on the future direction of prevention and health promotion, we believe many lessons from the development and sustainability of the MPSI may be relevant for students and faculty wanting to broaden their impact. A prevention science framework has guided MPSI since its inception (Kellam et al., 1999). Consistent with American Psychological Association’s (2014) Guidelines for Prevention in Psychology, we define prevention as consisting of one or more of the following: (a) stopping a problem behavior from ever occurring; (b) delaying the onset of a problem behavior, especially for those at-risk for the problem; (c) reducing the impact of a problem behavior; (d) strengthening knowledge, attitudes, and behaviors that promote emotional and physical well-being; and (e) promoting institutional, community, and government policies that further physical, social, and emotional well-being of the larger community. (p. 285) Although the principles of prevention science are relatively simple and easy to convey, some of the more nuanced aspects of solving major societal prob- lems may be hard to discern for those unfamiliar with the principles of pre- vention (Kellam et al., 1999). Equally important, in our opinion, each field that intersects with prevention science brings its own historical perspectives and training that may impede the application of these principles. With regard to prevention and health promotion scholars, we believe the most important and relevant lessons include the following: connecting small ideas to big solutions, matching intervention targets with goals, developing reliable and 134 Journal of Prevention and Health Promotion 1(1) systemic monitoring data streams, ensuring data and prevention efforts account for cultural context, and helping people/systems change. Connecting Small Ideas to Big Solutions One of the most perplexing comments we have heard repeatedly over the years from many students and colleagues in prevention and health promo- tion–related fields is that nobody funds their particular research interests. Initially, we attributed this mistaken perspective held by many scholars to institutional myths perpetuated by some of their prior mentors who them- selves experienced the inevitable rejection of some of their research ideas by funders. This perspective provided an unsatisfying explanation though, because it left little room for altering these perspectives. More recently, it occurred to us that an overlapping explanation may be that some scholars have not been mentored on how to connect their specific research interests to broader initiatives such as national public health or educational priorities. First, people who write grants for a range of funders quickly learn that the language of any given field does not easily translate to other fields. This statement is true even for fields with seemingly high levels of overlap such as counseling, school, and clinical psychology. A primary skill in grant writing is learning to convey ideas in the language that a funder will understand. For foundation grants, sometimes this requires heavy use of lay language. For federal funders, it requires the nuanced use of scientific language that appeals to the funder’s priorities. Second, funders will not be interested in your ideas simply because you believe they are intuitively appealing and important. Everyone believes his or her work and ideas are important. The task is to convey the concepts in a way that others can easily see how your ideas are part of the solution to big prob- lems. If you are unable to show how your ideas connect to important national priorities, then it is reasonable for funders to decline to invest in your ideas. Sometimes that simply means that you need to get better at connecting the dots between your interests and the funder’s priorities. Child Depression Example My (K.C.H.’s) initial work in children’s mental health focused on articulating a comprehensive theory of child-onset depression and then identifying and testing proximal causes, especially modifiable aspects of the social environ- ment that contribute to depression risk (for detailed discussion, see Herman et al., 2010). Curiously, though, I have never had a grant funded with a pri- mary focus on child depression. There are no journals devoted to the topic Herman et al. 135 and there is limited funding for it. I might have easily concluded that funding for child depression was so rare that it made my work unfundable. Instead, because I had been well-mentored, I was well aware of the need to connect my interest, my theory of how depression developed and could be prevented, with national public health and education priorities. A large strand of my research has focused on specifying developmental pathways to depression in youth and identifying universal as well as cul- ture-specific precursors to depression. An early paper reviewed the socio- cultural contributions to depression (Parks & Herman, 2003). Some of my work has identified common pathways to depression in young children including early language (Herman et al., 2016), social (Herman, Cohen, et al., 2018), and academic skill deficits (Herman et al., 2008; Herman, Hodgson, et al., 2020; Herman, Lambert, et al., 2007; Herman, Ostrander, Walkup, et al., 2007), as well as aspects of the home environment (Ostrander & Herman, 2006). Other work has highlighted the unique cul- tural aspects of depression including the relative role of family cohesion/ conflict and particular cognitions (Herman, Ostrander, & Tucker, 2007), racism experiences (Lambert et al., 2009), and perfectionism (Herman et al., 2013) for Black youth living in urban contexts. I also explored unique predictors of depression among youth in China living in poverty (Herman, Bi, et al., 2012). In line with the prevention science research cycle, I also investigated the effects of parenting and classroom management interventions that manipu- lated hypothesized causes of youth internalizing symptoms. The first paper was a randomized control trial from an existing data set, which found that a parenting intervention could reduce child depressive symptoms, in addition to its known and targeted effects on externalizing behaviors (Webster-Stratton & Herman, 2008). In a second paper, again using data from an existing ran- domized controlled trial (RCT), we found that integrated parent, child, and teacher interventions yielded stronger effects on reducing child internalizing symptoms (Herman, Borden, et al., 2011). These intervention studies are con- sistent with the prevention science notion of “malleability through experi- mental manipulation” (Kellam et al., 1999); that is, showing that altering a proposed causal mechanism specified by my conceptual model (parenting behaviors, school contexts) caused change in the outcome (internalizing symptoms). As such, the findings provide additional evidence that the mech- anism serves both a causal and maintaining function of child symptoms. All of these papers provide support for a primary thesis of my conceptual model, that family and school environment characteristics and parenting behaviors play a central role in the development and maintenance—or alternatively, the mitigation—of child depressive symptoms. 136 Journal of Prevention and Health Promotion 1(1) It is this big picture understanding of the contextual antecedents of depres- sion that ultimately allowed me to connect my work to funding priorities. Two of our large federal grants focused on supporting teacher skills in providing nurturing and effective learning environments, essentially antidotes to the known school risk factors for child depression. The first grant focused on evaluating the Incredible Years Teacher Classroom Management program for elementary school teachers (Reinke, Herman, Dong, et al., 2018). An ongoing grant is evaluating the CHAMPS classroom management program in middle schools (Herman, Reinke, Dong et al., 2020). Another stream of funding sup- ports student skill development in self-management strategies (Thompson et al., 2011). And finally, two recently funded grants focus on supporting prin- cipals to provide effective, safe, predictable, and nurturing environments for an entire school. All of these projects focus on providing better environments for all students, which include the environments known to be helpful for youth with depression. I would have never been funded to investigate these impor- tant research questions had I not first been able to articulate the big ideas of what causes child depression for myself, and second been able to communi- cate these ideas in ways that aligned with funding agency priorities. A Public Health Approach: Match Intervention Level to Social Change Goals In training psychologists and educators, one thing we have been struck by is that many students have great difficulty in learning to think and concep- tualize problems using a public health lens. On one hand, this makes perfect sense given that most students were attracted to the field because of their interest in doing individual or micro-level counseling. On the other hand, limited awareness of a public health perspective creates a disparity for many students who want to create broader social change. Individual coun- seling is an excellent tool in our repertoire for changing individual out- comes, but by itself it fails to alter the societal and contextual risk factors that create and maintain the problem. In essence, to focus on the individual as a principal route for changing larger social issues is myopic and mis- guided. Instead, solving major societal problems requires a focus not only on helping individuals but also on altering the risk and protective condi- tions that surround the individual (Herman et al., 2010; Kellam et al., 1999). For example, if your passion and your career goal are to provide more effective interventions and supports for students who experience racism, then individual counseling may be an important tool to reduce the adverse impact of these experiences and a public health orientation may not be Herman et al. 137 necessary. If instead your goal is to reduce institutional racism in colleges or society more broadly, individual counseling is unlikely to make much of a dent in that problem. Instead, you need more systemic tools and frame- works to broaden and guide your work. To overcome these challenges, we infused public health concepts and strategies into much of our coursework for counseling, educational, and school psychologists, as well as social workers. Orientation coursework in each field includes examples of epidemiology and public health interventions in educational and psychological contexts. For instance, students learn about strategies for triannual screening entire schools and districts for reading, math, or social emotional problems and using that data to inform implemen- tation of selective and indicated supports for students in need. In later course- work, students learn how to implement such screening and prevention approaches and, during practicum experiences, participate in their actual implementation. Other courses use this public health orientation to expand the students’ thinking by asking them to conceptualize how these strategies can be used to address other social problems of interest to educators, psy- chologists, and social workers. For instance, a course on developmental psy- chopathology focuses on the timing of developmental risk and protective factors and their relationship to the emergence of psychopathology. Students use this information to conceptualize the common malleable precursors to psychopathology and to strategize the optimal timing of screening and early intervention strategies to interrupt the casual sequence. MPSI Example Consider the goals of the MPSI, which include reducing the prevalence and burden of youth mental health problems. If we solely went about our business developing individual or even small group treatments for youth mental health concerns, our success would be extremely limited. For example, in some schools with high needs, 50% or more of youth may present with one or more serious behavioral or emotional concerns (Tolan, 1996). Schools or commu- nities would never have the resources to provide intensive individual coun- seling services to meet the needs of such a large segment of the population. Instead, a public health approach is needed. In this framework, the only real- istic way to address the needs of all students is to provide stronger universal and selective supports for students to reduce the prevalence of youth with intense needs. Thus, if scholars want to be true prevention scientists, our theories and intervention skills need to be much broader than those situated within an individual-oriented approach to the world. 138 Journal of Prevention and Health Promotion 1(1) Surveillance and Data Streams In line with a public health perspective, prevention and health promotion scholars with passions to solve societal problems need to learn how to collect and use surveillance systems. Surveillance is an epidemiology strategy that includes collecting continuous data streams that monitor targeted problems and associated risk and protective factors (see Herman, Riley-Tillman, & Reinke, 2012). Although many educators and psychologists are trained in traditional approaches to measure development and interpretation, such train- ing is insufficient in itself to be useful in addressing real-world concerns about day-to-day decision-making. Routine use of data usually fails because most measures are too burdensome to be collected regularly and too insensi- tive to capture the critical elements of change. Coalition Example An example of a comprehensive surveillance system includes the student and teacher checklists we developed as part of the Coalition (Reinke, Thompson, Herman, Holmes et al., 2018; Thompson et al., 2017). The Coalition is funded by an innovative sales tax that voters passed in 2012 to support youth mental health. Based on the tax, every four dollars that consumers spend in our county generates one penny for the fund, which accumulates to nearly US$7 million per year. After the tax passed, superintendents from all six school districts in our county bonded together to identify the most effective use of these funds based on their collective needs. They invited the second author (W.M.R.) to attend an early meeting to hear her perspective. Historically, leaders in our local school districts were skeptical of university partnerships because many of them had prior negative experiences with researchers. In particular, our schools reported concerns about “helicopter” research where researchers would collect data from students and teachers for their own purposes and then not work with the schools to share or apply any knowledge that was gained from the project. Our team had worked for several years to overcome these perceptions, providing clinical services and supports, and trying to meet dis- tricts and schools where they were at to meet their needs. We believe this patience, not insisting on doing research in their buildings, helped develop positive relations with many leaders who came to view us as a resource. It was this context that led them to invite us to be part of the Coalition. We recommended that the superintendents pursue a public health solution to the high rates of youth mental health concerns they were all experiencing. As a critical step, we encouraged the Coalition to administer a surveillance Herman et al. 139 tool triannually to document the patterns of youth social emotional symptoms and precursors. Although many other youth mental health screening tools were already available, the superintendents expressed concerns about their recurring costs (typically US$1 per student, each administration), the time burden for teachers to complete (often hours per class), and the excessive identification of students in need of services that would overwhelm each school’s capacities to serve them. Based on these concerns, we proposed to develop the Early Identification System (EIS), a brief, comprehensive yet efficient tool for monitoring youth social emotional health in schools and sought funds from the county tax to do so. The EIS was based on a careful literature review of risk and protective factors of youth mental health concerns (see Huang et al., 2019). It includes both a teacher version (K–12) and a student version (3-12). The teacher EIS checklist asks teachers to identify students in their classroom exhibiting par- ticular risk for emotional or behavior problems. Because the checklist does not require the teacher to rate each child on all risk factors (instead it just asks them to check “yes” for students with the risk), we reduced the time burden for rating an entire classroom down to about 10 min. Similarly, the student checklist is brief (2–10 min) and is completed online. The tools are easy for users to understand; a brief script is provided to them about the purpose and use of tool, and no training is needed to complete the measure. Each teacher and student has a unique user ID, populated by our web-programmer based on information provided to us from schools regarding student rosters for each class. Regional Coordinators, Coalition technical assistant staff members, support schools by helping them identify times to administer the surveys and problem solve occasional technology or access issues. Over time, each school becomes increasingly independent as they gain experience administering and interpreting the EIS. As soon as the EIS checklists are completed, schools have access to an online dashboard that presents their data to them. Notably, the EIS scores are based on local norms, where risk is calculated based on mean scores within a school building. This helps identify the students most in need of services relative to their immediate peers and helps limit the burden on a given system. For instance, a school in a distressed neighborhood with rates of family poverty would likely have very high percentages of their students deemed to be at or in risk compared with national normative comparisons, but the locally normed EIS would keep the school focused on a more man- ageable number of students most at risk. The EIS data are also calculated based on z scores in this local context, so the students most at risk are always around 5% of the student population (i.e., 2 standard deviations above the local mean). 140 Journal of Prevention and Health Promotion 1(1) These checklist data highlight student-level risks, which allow school per- sonnel to make data-based decisions about how to improve the socioemo- tional context of their building and/or to provide additional screening and supports to individual students identified with needs. Equally important, these data can also be aggregated to examine risk across an entire grade level, school building, district, or county providing school and community leaders with detailed population-level information useful for informing policy devel- opment, applying resources, or selecting universal intervention strategies. Using these systems, Coalition schools gather student and teacher checklists on nearly 25,000 students 3 times per year to provide ongoing information about the correlates of youth mental health concerns. Regional Coordinators support school personnel in collecting, interpret- ing, and using the data to make decisions about universal, selective, and intensive individual supports that are needed in a building (Reinke, Thompson et al., 2018; Thompson et al., 2017). Coordinators are employed by the university and come from a variety of training backgrounds includ- ing school psychologists, school counselors, and school social workers. Each Coordinator is assigned to provide technical assistance to approxi- mately five school buildings. In particular, they provide training to school problem-solving teams, typically composed of counselors, special educa- tors, teachers, and administrators, about the model and the use and interpre- tation of the EIS. Based on school needs, they also help conduct universal prevention interventions (e.g., whole school or class trainings) and selec- tive and indicated interventions (e.g., small group or individual behavior support plans) and train school professionals in each building to do the same. For instance, one school’s data showed a high prevalence of organi- zational skill deficits. It would have been unrealistic to provide each stu- dent in the building with intensive individual counseling to improve their organization and planning skills; the school opted instead to provide whole school trainings for all students. Students who continued to struggle after receiving this training then received additional more individualized sup- ports. The ongoing data streams then informed the school whether their efforts were helping reduce the overall prevalence of the problem. Several recent papers highlight the promise of the Coalition model and the EIS in particular (Herman, Reinke, Thompson et al., in press; Huang et al., 2019; Reinke, Herman, et al., 2020; Reinke, Thompson, et al., 2020). A series of papers have supported the factor structure and measurement invariance of the EIS, and the acceptable to excellent diagnostic accuracy of each subscale across elementary and secondary samples. Even more important, a paper cur- rently under review found that students in Coalition schools have experienced a steady decline in the mean slope of youth mental health concerns over the