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The Prevention Dividend Project: Thinking with Clarity, Investing with Vision

Submitted by Susan Himel, Research Consultant for the Prevention Dividend Project and Graham Clyne, Research Director for the Prevention Dividend Project.

A. Introduction

The Prevention Dividend Project was initially discussed at the 1999 meeting of the Sparrow Lake Alliance ( when Dr. Paul Steinhauer posed a challenging question: If prevention really works, why do we seem to be losing the battle for public support?" Recognizing that business leaders service clubs, governments and ordinary Canadians are asked every day to support a wide range of different and worthy causes, the group acknowledged that there was a need to better demonstrate the impact of prevention and health promotion initiatives.

Moving from the idea to the launch of project did not take long. The concept has received strong support wherever and whenever it has been discussed. The "Prevention Dividend Project" was proposed and supported by a number of interested groups. Specifically, the goals of the project are as follows:

* To demonstrate where good investments can be made in prevention and early intervention programs and strategies

* To showcase different examples - from infants to seniors - of where a measurable "return on investment" can be calculated,

* To share useful tools and methods that can be used by groups interested in calculating the economic impact of their work,

* To create a multimedia presentation around the effectiveness of prevention that can be shared with local, provincial or national decision-makers.

B. The Challenge

Last April [1999], the Prevention Dividend Project team set out to explore the difficult and largely unaddressed question: How can we tell if prevention programs are a good investment of public and charitable resources?

Taking a generalist approach, we looked for programs and initiatives - anywhere in the life cycle - that succeeded in assessing and demonstrating their impacts. Anticipating that these illustrations would teach us something about effectiveness, cost effectiveness, and its measurement, we began a national, and then international, search for good examples.

As our inquiries and contacts spread out across the country we encountered two interesting and consistent responses:

-"Yes, this sort of work would be most valuable - please keep me informed", and;

-"No, I'm not aware of any prevention programs that have done this sort of analysis".

Many people added a cautionary comment, suggesting that assessments of costs and benefits might not demonstrate what we were looking for, and worse, might be used to argue against preventive programming. A rather inauspicious start!

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C. Findings to date

Not easily discouraged, we have spent the last number of months identifying where and when prevention programs have managed to successfully measure their impact. The results - and our understanding of the challenge - have produced some interesting findings. To summarize:

* There are quite a number of prevention programs, in different sectors, which are able to demonstrate their effectiveness - and cost effectiveness - both in the short and longer term. While the methodology differs, and can usually be challenged in some fashion, the concept of investment and measurable return can be shown with some reliability.

* Cost effectiveness is easier to demonstrate when the interventions themselves are effective and, as a consequence, reduce the use of health care, justice/corrections, income support, and child welfare systems - arguably the most expensive and/or least effective of our publicly supported programs. Similarly, narrowly targeted programs, focused on smaller subsets of individuals are better able to show measurable results than broad based prevention and/or health promotion strategies.

* There are significant problems in the design and delivery of prevention programs that account for the less than robust results we encounter. Indeed, "negative outcomes" are detectable in a number of programs and target groups. Similarly, programs aimed at individual risk factors, where the fundamental elements of success (e.g. income, housing, education) are absent, represent an indirect and unlikely way to effect more significant or measurable outcomes. It's a "mug's game" as one informant suggested, or more politely, an issue of inadequate "dosage".

* Scientific models that require a clear demonstration of causality are an extremely difficult way to analyse the effectiveness (and cost effectiveness) of prevention programs. Rigorous control for variables is usually impossible and longitudinal impacts difficult to detect and/or describe.

This does not however, obviate the need to improve the quality of data, and the development of the skills, methods and resources that are essential for informed decision-making.

In the interim, we can also improve our ability to use credible alternatives including strong correlative outcomes at a program level; supportive population based indicators; and providing good examples that can be described in accessible and understandable ways.

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D. Moving Forward

To date, we have had the opportunity to discuss and explore these concepts with over 300 people working in areas related to prevention and health promotion. A few clear directions have emerged and we have been encouraged to concentrate our efforts in the following:

* Continue to work to identify good illustrations of where and when prevention and health promotion strategies can clearly demonstrate their impact and effectiveness - particularly those that focus on the relative costs and benefits,

* Assemble and make available the sorts of tools, models and methods that can be adapted and used by community based practitioners so that they can do a better (if slightly imperfect) job of demonstrating and expressing the impact and/or cost effectiveness of their particular prevention programs,

* Provide a forum and a network of resources that will enable people to better and more appropriately describe the worth of prevention and health promotion - despite some of the limitations discussed above. The growing competition for public and charitable support is a dynamic that simply cannot be ignored.

In support of these directions, the research team at the Prevention Dividend Project will continue to find, develop and provide the sorts of resources and materials that we have recently begun to post on the web site. Please visit and bookmark our site:

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E. Economic Assessment and Prevention Effectiveness

Plans are also underway with a number of partner organizations to host a day-long session that will bring together some of the best thinkers and practitioners interested in the evolving science of economic analysis and cost effectiveness. Tentatively scheduled for mid February 2001, this event will focus on a few key questions:

? What are the underlying principles and concepts that form the basis of sound economic evaluations? What are the basic rules for applying an economic approach to describe effectiveness and/or cost effectiveness? Where should we start?

? What are the real problems behind the "less than robust" results we find when we try to assess the measurable outcomes of prevention programs? What can we, and should we, be doing to improve our ability to measure effectiveness?

? Given the complex realities of working in actual communities, how do we best measure and express the short and longer-term impacts of prevention programs? Is cost effectiveness analysis a useful tool - and in what circumstances? What can we learn by looking at some case studies?

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F. For More Information

If you know of any prevention/early intervention strategies in your area where some effort has been made to capture the economic impacts and effectiveness of the program, we are interested in hearing from you.

Special thanks to all of you who have already so willingly shared your research materials - and your personal reflections - on the challenging issues discussed above. If you are interested in getting more information about the symposium, or any of the other concepts and findings discussed in this OHPE feature, we would be pleased to hear from you. Please visit our web site at - or call us at 519-433-3913.

General inquiries should be addressed to

The Prevention Dividend Project: Thinking with Clarity, Investing with Vision

Thanks also to our many supporters and sponsors including: The Sifton Group; Bobnis.Com; Sparrow Lake Alliance; OPC (Ontario Prevention Clearinghouse); Human Resources Development Canada; Health Canada, the Foundation for Learning and Social Enhancement