Guest editorial: The Pivotal Role of Prevention Science in this Syndemic

Prevention scientists must mitigate the impact of the syndemic on marginalized populations Health disparities COVID 19 Economic disparities Systemic racism

Guest editorial by PRC Affiliate Faculty Member Dr. Diana Fishbein

  • President, National Prevention Science Coalition to Improve Lives (NPSC) 
  • Director, Program on Translational Research on Adversity and Neuroscience (P-TRAN), Edna Bennett Pierce Prevention Research Center and Department of Human Development and Family Studies, Penn State
  • Director, Translational Neuro-Prevention Research, FPG Child Development Institute, University of North Carolina

At no time in history has the value of prevention science become so evident to the American public than in the midst of a syndemic (e.g., simultaneous crises.) The COVID-19 crisis, in particular, has drawn attention to the dire need for a proactive, not reactive, approach to prevent the spread of the virus and its devastating health and economic consequences. The crisis has also highlighted for the nation ways in which Black and Brown people have been under-served, under-resourced, and frankly denigrated. As a result, minority populations are at much higher risk for infection, hospitalization and death than Whites. And the racial divide has rapidly become even more glaring, with an exacerbation of already extraordinary levels of poverty for an otherwise affluent nation, and soaring rates of mental health problems, substance abuse and dependence, domestic violence, child maltreatment, suicide and educational lapses especially impacting marginalized groups. These disparities have existed for 400 years, but the pandemic has exposed the deep-seated nature of the problem for those who did not previously fully appreciate its magnitude.

Further amplifying the uneven impacts of the COVID-19 crisis, police shootings of several unarmed Black people plunged racial injustice onto the national stage, bringing millions of people across all demographic groups to the streets and to their knees in fervent protest. Clearly, this is the time to act, the time to heal, and the time to transform not only mindsets, but systems. The convergence of these events presents the nation with an unprecedented opportunity to make deep inroads into the problems of inequalities, health disparities, poverty, systemic racism and other inequities across sectors of our society.

Prevention scientists have an especially germane role to play in mitigating the impact of the syndemic on marginalized populations. The objectives of prevention science are to (a) identify malleable risk and protective factors, (b) assess the effectiveness of programs, interventions and policies that target those factors, and (c) develop an optimal means for dissemination and diffusion of that knowledge. Prevention strategies avert a problem before it emerges or worsens, avoiding adverse outcomes and their costs, and enhancing conditions conducive to the health and wellbeing of individuals and strong families and communities. By intervening prior to onset or escalation of any given problem—whether it be at the individual level or within systems—a preventative approach can bolster underlying influences, leading to a cascade of positive outcomes.

In keeping with these objectives, prevention science has exerted significant social impacts on individuals, families and communities over the past 30 years. We have learned how to prevent/reduce academic failure, tobacco use, teen pregnancy, addiction, violence, mental health problems, and many other negative outcomes. And we have learned how to promote healthy development, well-being, supportive parenting, and community cohesion. However, despite these remarkable successes, prevention strategies are chronically underutilized and underfunded, and as a result, there are few national or state level policies to institutionalize these programs, which the research suggests is warranted. In large part, this reality is due to the lack of awareness on the part of the public and policymakers of the wealth of rigorous research findings from prevention science. Scientists can speak to these issues with authority to exert an influence and impact the social determinants of health by engaging in the active translation of our work.  

The role for science in addressing these structural impediments to health and well-being of all people has never been more clear. This syndemic is presenting prevention scientists with a rare and unmistakable opening to address the legacy of inequities and racist public policies and practices. There are two pressing calls to action. First is the need for programs of research to apply a racial equity lens. Doing so means that, at the core of our work, we actively seek to illuminate disparate outcomes and paying attention to race and ethnicity while analyzing the phenomena under study, identifying solutions and developing novel and more inclusive approaches to defining success. In responding to this call, it is fundamentally critical to lift up the voice of the community and, in essence, nurture a co-equal partnership for the co-creation of solutions. Second is the call for researchers to learn how to effectively communicate scientific knowledge to the public and to advocate for reforms based on the science in the policy arena.

This commentary urges prevention scientists to broaden the reach and significance of our work given its enormous potential to exert positive impacts on the phenomenon we study, at scale. This objective can be achieved, in part, by embracing approaches to prevention research that, at its core, is sensitive to race, that confronts and attempts to alleviate racial injustice, and that delineates effective methods for science advocacy. The approaches outlined here are not fully representative of the full range of research and advocacy activities in which prevention scientists can adopt to pave the way for science to advance equitable practices and policies, but they are a start. Overall, the message is that prevention scientists should feel secure and defensible in taking bold action to measurably advance social, health and racial equity amid this syndemic.

Adaptations to Research Agendas

The research agendas of prevention scientists are geared toward multi-level solution-based strategies that are inherently actionable. As such, it is incumbent upon us to ensure that the “end-users” (e.g., practitioners, community stakeholders, policymakers, agency administrators) are aware of the field consensual knowledge and practices we have amassed, that drivers are in place to implement those practices into delivery systems, and that policymakers are compelled to institutionalize what works in their communities. Doing the work needed to entrench prevention science into mindsets, practices and policies is our highest calling. Ultimately, the extra effort it takes accomplish these objectives will foster inclusiveness, diversity and equity in our work and in our ecosystem.  

First, develop well-tested protocols that (a) identify thresholds for translating evidence (e.g., sufficiency of the evidence, criteria for designating programs as evidence-based, field consensual knowledge), (b) instill effective communications skills, (c) teach strategies for interacting with different constituent groups (e.g., segments of the population, policymakers, community stakeholders), and (d) guide exercises to map legislative agendas to the available evidence. Learning how to effectively advocate for and support a careful, thoughtful, and evidence-based policy approach will facilitate widespread adoption and implementation of demonstrated prevention strategies and concepts.  

Second, diversify the scientific research community addressing phenomena that are outgrowths of racial and ethnic disparities to be more representative of, and sensitive to, the diversity of populations (e.g., vulnerable, stigmatized, oppressed), focal concerns (e.g., disparities and inequalities) and contexts (e.g., poverty and other adverse conditions) under study is especially critical. Prevention science is currently underrepresented by Black and Brown investigators and practitioners.

Third, conduct research to develop strategies to build the political will and support for programs and policies that increase social equity and welfare. Strategies to move the needle down this track include developing methods to raise awareness of the pervasiveness of inequities in health and promoting empathy and support for addressing them. In parallel, research is needed to determine how to effectively increase capacity of individuals and communities to participate in intervention efforts, such as what we see with community coalitions made up of agencies, organizations, faith groups, and citizens, shown to strengthen the social fabric. And advancing and integrating the work of implementation scientists will help us to delineate best practices for embedding large-scale efforts to reduce racial prejudice, ideologies, and stereotypes in the larger culture that frame policy preferences that underlie and perpetrate inequities.

Fourth, intervention evaluation studies can begin to model measures of implicit bias, perceptions and experiences of racism, and racist practices as outcomes. To date, very few studies examine whether effective preventive interventions reduce racism or racist practices; only interventions that are specifically designed to directly address the phenomena include these measures as outcomes. It is possible, for example, that preventive interventions targeting other outcomes (e.g., substance use, violence, community cohesion, academic performance) may directly affect deficits in self-image due to perceptions of racism as social emotional and competency skills improve. Or intervention-related improvements may indirectly impact the implicit biases of other players in the recipients’ sphere of influence. A key question is, as the playing field is increasingly equalized, do racially-driven attitudes, behaviors and practices change accordingly? And relatedly, does (or can) the needle move in system-level practices and policies in response to the benefits demonstrated by preventive strategies? Because no such research has been conducted, we cannot yet cite evidence of the impacts of preventive intervention on any aspect of racism.

Fifth, the bread and butter of prevention research has historically been on the development, implementation and scaling of interventions. The success of this agenda as described above is remarkable. However, increasing and sustaining those impacts can be achieved by broadening the scope and scale of resultant interventions, and focusing greater attention on methods that lead to the institutionalization of those that are most effective. Constraints are, in part, due to the reality that the research process is largely dictated by time-limited grants.

On the other hand, the normalization of prevention principles and practices at the community level has the greatest potential to achieve population level effects, ultimately equalizing the playing field for all segments of society. Normalization can be facilitated in two ways. First, incorporating into our daily lives the practices and principles that undergird intervention impacts—the “kernels’ or active ingredients—can transform the way adults interact with each other and their children. These fundamental units of programs and interventions have been shown experimentally to influence specific behaviors. Integrating a wide range of these practices and principles into daily interactions has potential to more broadly and sustainably promote health and well-being, independent of any particular intervention or grant.

The second interrelated aspect of normalization involves increasing knowledge; changing attitudes and mindsets extends from a better understanding of the science of human development and the fundamental importance of the manner in which adults interact with each other and their children. Making scientific knowledge widely accessible catalyzes change in attitudes and behaviors. Recipients of this information then become change agents themselves as they apply this new information to their associates, organizations, and systems within which they interact, and they diffuse it throughout their spheres of influence. The end goal is to spur a shift in cultures, priorities and practices that, in turn, influence policies, distribution of resources and system level relationships. For example, incorporating these principles and practices into cross-sector service delivery systems substantially expands the scale at which benefits are achieved.

Sixth, and perhaps of greatest importance, more attention to tackling the underlying sources of exposures to social determinants of poor health outcomes has potential to exert broader impacts on the phenomena we seek to prevent than solely focusing on the attenuation of individual and family level adverse consequences of adversity. While the latter approach is no doubt critical, increased investments in science-informed practices and policies to reduce systemic inequalities, poverty, marginalization and discrimination, and to promote health equity and social welfare, altogether promise to exert wide-scale impacts.

Prevention scientists, by nature, have already embraced an upstream strategy (e.g., programs that prevent substance use in adolescents, provide early education, strengthen skills to resist poor developmental outcomes and support positive mental health) to avoid downstream costs (e.g., the financial and human burden to communities associated with treating drug addiction, juvenile delinquency, involvement in the criminal justice system, and school dropout). And when implemented effectively, the application of our well-tested practices and policies can lead to substantial cost-savings. Focusing our attention further up the stream, beyond the individual, family and even the community level, we find the roots of the problems we strive to solve in cultural, economic, linguistic, attitudinal and structural sources. Directing our energies toward these fundamental streams of influence will produce transformational results.

Building Bridges between Scientists, Policymakers and the Public

Embedding a culture of prevention into the mindsets of the public and the decision-making process of policymakers requires that scientists systematically convey the relevance and importance of prevention; doing so will reduce the burden of phenomena we aim to prevent, minimize errors, lower costs, narrow disparities, and improve outcomes for all people of all backgrounds and at all life stages. We need an empirically tested science-to-policy protocol for experts, practitioners and advocates across fields and sectors to increase public understanding of prevention and motivate people to demand systems and a culture that supports it. And it is essential that scientists are comfortable in this “end-stage” (science-informed policy reform) translational role. A process and vehicle in place allowing for clear articulation in lay terms of how research can be used to create and demonstrate practical prevention strategies and their cost effectiveness.

Prevention scientists should feel emboldened to influence policy for the betterment of society. We have amassed a large body of field-consensual knowledge about the prevention of virtually every common and costly health-related problem. And a considerable arsenal of evidence-based interventions—at the individual, family, school and community levels—has been generated. Prevention systems housing a menu of effective programs have also been embedded in some communities for systematic delivery to populations who stand to significantly benefit. Legislative processes can support the implementation and scale-up of these evidence-based programs and policies in communities across all segments of society.

Innovations in communications science play a critical role in the translational research process. After two decades of communications research, it has become apparent that a primary reason for our inability to prevent preventable conditions is that the public is unaware of, under-appreciates, or discounts the power of prevention and thus does not prioritize it within a policy arena. Prevention researchers working closely with communications specialists and community stakeholders will be able to identify heretofore unexplored channels to actuate the results of the research.

For example, one research question relevant to health disparities is, how can social-change communicators best promote conversations about race and racism in ways that help people understand, and encourage them to act and support solutions that advance equity? And throughout the communications process, it is vital that all voices and perspectives are heard by change agents. Systems change only works when citizens are engaged and connected with local community leaders and policymakers.

Shifting narratives to more effectively communicate the importance and utility of the knowledge derived from prevention science can lead to positive effects on so many levels. Moreover, since marginalized populations are especially hard hit, conveying information to key stakeholders about the dramatic effects of these strategies on health and well-being of vulnerable populations is vital. Prevention must become part of the American zeitgeist, as firmly entrenched as pragmatism and as cognitively accessible as health promotion.

In the advocacy realm, the work should focus on what policy reforms are needed to begin to weed out inequities and racism. The best way to direct attention to these priorities and compel action to reduce inequalities is for society to focus on common ground, highlight our interconnectedness, and foster solidarity. In the wake of the Covid-19 crisis, our collective ability to rebound may ultimately hinge on protecting and equipping our most vulnerable racial-ethnic minority groups and any susceptible individuals within those populations. A multitude of foundations and advocacy networks are stepping up and advancing messages that unite and propel us toward a better future. It is, in part, up to us to bolster the movement in scientific grounding.

Prevention scientists are ideally well positioned to exert an influence, all committed to be an accountable actor and supportive ally in systematically eliminating racial inequity and a broad range of other inequalities. Prompting our efforts should be the reality that our collective ability as a nation to rebound from the devastation due to this virus may ultimately hinge on protecting and equipping our most vulnerable racial-ethnic minority groups and any susceptible individuals within those populations. We are seeing conclusive evidence that a powerful collective advocacy bringing thoughtful and deliberate intent can effectively sway action of the federal government as it relates to health crises like the current pandemic, which is deeply encouraging.