1. Inside the Black Box of Prevention: Implications for Health Promotion

2. 2 Prevent (pri vent  ) vt. [ L. praevenire, to anticipate.] 1. To act in anticipation of. 2. To keep from happening. Prevention (pri ven  sh  n) n. The act of preventing.

3. 3 Possible Prevention Impacts Positive Processes Increase Keep from Decreasing Slow the Rate of Decrease Negative Processes Reduce Keep from increasing Slow the rate of increase

4. 4

5. 5 Rationale of Health Promotion Public Health Public Health Economic Economic Common Sense Common Sense Moral Imperative Moral Imperative

6. 6 Classic Model of Assessing Effectiveness

7. 7 Traditional Health Education Diffusion Stages of Change BehaviourSkillsAttitudesKnowledgeDialogueAdoptionTrialInterestAttentionAwarenessMaintenanceActionPreparationContemplationPre-contemplation

8. 8 Norm Climate Threshold Model

9. 9 Norm climate: The constellation of norms, attitudes, practices in ones perceived social environment.

10. 10 Characteristics of the model No visible change at first No visible change at first Growing awareness/dialogue Growing awareness/dialogue Increased visibility Increased visibility Modelling Modelling Shifting precursers Shifting precursers Threshold reached Threshold reached Change is outside in/inside out Change is outside in/inside out Generational forgetting if we stop Generational forgetting if we stop Takes time Takes time

11. 11  No Visible Change at First

12. 12 Growing Public Interest

13. 13  Reach Threshold

14. 14 Norm Climate Shift Precursor Change

15. 15  Time Can be Short or Long

16. 16  Generational Forgetting Can Occur

17. 17 Increased Difficulty As Prevalence Decreases/Increase

18. 18 Norm Climate Is Affected by Environmental Constraints

19. 19 Essential Elements Consistency Consistency Durability Durability Comprehensiveness Comprehensiveness

20. 20 Norm Climate Threshold Model Threshold Point Desired Effect (Reduction in this case) Sustained messages and policies over TIME

21. 21 Evidences of The Model at Work:

22. 22 1. At Least Three Ex Post Facto Cases

23. 23 2. Reverse Seems True: E.g., Trends in Cannabis use, 1990’s

24. 24 3. Looking At Qualities of “Programs” That have Appear to Achieve an End Stage Change: Comprehensive Comprehensive Enduring Enduring Many channels Many channels Over time Over time Even with these, effects erode over time, showing evidence of need for on-going, outside –in effort to shift norm climate Even with these, effects erode over time, showing evidence of need for on-going, outside –in effort to shift norm climate

25. 25 4. Epidemiological Guidelines for Establishing Cause - Effect Time-ordered Time-ordered Shown across issues Shown across issues Shown across studies Shown across studies Based on sound scientific reasoning Based on sound scientific reasoning Consistently seen Consistently seen

26. 26 Recommendations Do not expect single programs to have end effects Do not expect single programs to have end effects Realize change is slow and not linear Realize change is slow and not linear Reduce expectations of separate programs and policies Reduce expectations of separate programs and policies Ensure a consistent message Think in years, not weeks or months, of duration

27. 27