A Focus on Preventive Care:
••Winter 2004/Vol. 8, No. 1

KP in the Community

PEACE SIGNS: A Sustainable Violence Prevention Collaboration Between Managed Care and
School Health Programs| pdf >>

By John Fontanesi, PhD; Jill G Rybar, MPH; Neil Alex, MD; Howard Taras, MD; Vivian Reznik, MD

Presented in part as "Linking with schools: a managed care perspective," at the 9th annual Cajun Christmas Conference (National Child Health Leadership Conference), New Orleans, Louisiana, December 1999; as "A preventive mental health collaboration between managed health care and school health programs," at the 7th annual Behavioral Healthcare Tomorrow Conference, Washington, DC, September 24-26, 2000; and as "A model conflict resolution program: building on the strengths of school health managed care," at the 74th annual School Health Conference of the American School Health Association, New Orleans, Louisiana, October 25-29, 2000.

Introduction

The names of once-obscure American towns--Littleton, Colorado; West Paducah, Kentucky; and Santee, California­-remind us of the unprecedented tragedies that can occur if angry kids are not redirected. Our children are disproportionately the targets of violence, which has now become the second leading cause of death for children 10 to 19 years of age.¹ The Office of the US Surgeon General and the Centers for Disease Control and Prevention (CDC) have proclaimed violence a major threat to public health.

Localizing the consequences of violence as a public health threat is not difficult. In a 1999 CDC study of at-risk youth, 14% of San Diego County adolescents surveyed stated that they carried a weapon to school; 34.9% reported being involved in a physical altercation; and 4.8% reported that they required medical attention for injuries sustained in an altercation during the previous year.² Violence in adolescents does not exist in isolation; instead, violence proves to be associated with school failure,³ drug use, criminal behavior,⁴ and acting out sexually.⁴ In addition, the Adverse Childhood Experiences (ACE) Study carried out at Kaiser Permanente (KP) has established a link between adverse childhood events and adult health status.^5-7 This work adds a developmental trajectory to the literature showing a clear connection between pediatric behavioral problems and frequent physician visits^8-10 as well as between these behavioral problems and high utilization of general community resources.^11,12

Although various services are directed toward troubled adolescents, these interventions occur after the maladjustments become clinically significant--a time when the likelihood of rehabilitation is uncertain.¹³ In addition, the cost of such intervention is high: During the same period covered by the 1999 CDC Youth Risk Survey, the KP San Diego Service Area spent more than $2.8 million for psychotropic medication¹⁴ and referred children and adolescents to the Department of Psychiatry at a rate substantially higher than that predicted on the basis of membership growth.¹⁵ Paralleling the KP experience, the San Diego County Department of Mental Health spent more than $57 million for treating troubled youths during this same period.¹⁶

Instead of waiting for these patterns of maladjustment to crystallize, a coalition of health plans and school health personnel operating in San Diego County (the School Health Improvement Program, or SHIP) sought to build on an emerging body of research suggesting that adolescent violence and maladjustment have developmental roots in early childhood experience. SHIP (Table 1) includes many local health plans, school districts, the San Diego County Department of Health Services, and local members of the American Academy of Pediatrics; all of these groups are directly affected by the rate of adolescent maladjustment in the community.^17,18 SHIP recognized that implementing a successful violence prevention program required four essential components: 1) a theoretical framework to guide development; 2) a memorable, effective educational format that would provide a rallying point for unifying coalition efforts; 3) a "mapping" of available resources; 4) and a definition of program goals that reflected participants' needs in a measurable way. Startup funds of $110,000 were generously provided by the Kaiser Permanente Garfield Foundation.

The theoretical framework chosen was attribution theory, which for aggressive action describes a developmental sequence of emerging violent tendencies in terms that are amenable to change. To explain aggressive actions, attribution theory proposes that some children incorrectly attribute negative or hostile motives to the actions of others. This presumed negative intention affects the child's perceived response alternatives and creates a negative interaction cycle of rejection and isolation.^19-21 Early behavioral manifestations include feelings of sadness and isolation, expressions of aggression, poor academic functioning, and somatic complaints.²² Attribution theory
also states that social interaction is learned by "doing" (procedural learning) and not by "listening" (didactic learning) and thus offering a direction for intervention.²³

Research has also shown that a successful program requires a curriculum that teaches use of clarifying statements, provides consistent reinforcement of positive messages, highlights role models, involves parents, and includes peer-mentors.^24-29 To maximize coalition involvement and to unify the messages delivered to children requires a highly visible, visceral, memorable rallying point, which was accomplished using an interactive theater project produced by the KP Educational Theater Program (ETP). The theater consisted of two productions, Professor Bodywise (for children in grades K-3) and PEACE Signs (for children in the fourth through sixth grades). Both plays model positive conflict resolution, are developmentally targeted, and demonstrate how to clarify intentions of others. The value of interactive theater as a procedural learning tool has been documented by authors such as Pellegrini³⁰ and Fink³¹ and is particularly well described in the Critical Links monograph.³² The ETP productions were so highly valued that they proved a powerful incentive for schools to agree
to participate and to devote the resources necessary for the total program. The ETP productions' interactive modeling of conflict resolution strategies and methods fits the procedural learning format suggested by attribution theory.

Setting

Eighteen elementary schools in the San Diego Unified School District were included in the study. Each of nine control schools was matched with an intervention school with similar socioeconomic characteristics. Each school pair ("cluster") was administratively anchored to a local high school, was geographically contiguous, and had rapidly escalating populations of culturally diverse, school-aged children, primarily from lower socioeconomic families, living in multifamily housing. Between 75% and 100% of the students in each cluster were eligible for free or reduced-cost lunch.³³ All 18 schools had preexisting violence prevention programs whose curricula was either supplied by the school district or was chosen by the individual school's administration. The KP Southern California Institutional Review Board approved the protocol. Overall participation in the project was authorized by joint Memorandums of Understanding between the San Diego Unified School District and participating health plans.

Methods

The coalition evaluated each participating school for presence or absence of key elements identified in violence prevention research (Table 2). In schools where these elements were missing, the coalition program supplied technical assistance, curricula, and incentives. Curricula provided in classrooms were linked with the two interactive theater presentations by using as clarifying messages the same phrases used in the plays. Incentives and promotional material included items such as vests (for children selected by schools to participate in "peace patrols") and T-shirts emblazoned with the PEACE Signs logo. Technical assistance included helping school staff to ini
tiate peer mediation programs; providing health educators and mental health professionals to attend four "parent nights" to discuss principles of conflict resolution; distribution of resource and referral information for students in need of assistance; and teacher preparation for implementing lessons in conflict resolution. The coalition also prepared newsletter articles released to parents throughout the school year to reinforce and parallel the conflict resolution messages their students were receiving, Division of labor between schools and nonschool coalition members is listed in Table 3.

Data Collection and Analysis
A pre-post control group design was used to compare each of the nine intervention schools with the nine case-controlled schools. As the largest health plan in San Diego county--its membership includes 103,000 insured school-aged children--and with tight integration between its providers and the Health Plan, KP was able to track on an aggregate basis the health care utilization patterns of its members within the study schools. In addition, data on daily attendance, school nurse utilization, disciplinary efforts, and scores on a State of California competency test were obtained on an aggregate basis for both the intervention and control schools. Confidentiality of each Health Plan member and student was maintained consistently. The two-sided t test was used to compare control and intervention schools in regard to health care utilization, school attendance, and disciplinary suspensions.

Results

Table 4 shows that the program achieved a high acceptance rate among teachers and parents; and a substantial percentage of both continued to use the thematic messages contained in the program. Table 5 shows outcome measures; a statistical test of the difference between pre-post health care utilization comparing the intervention and control groups was significant at intervention but not at the control sites (p = -.01).

Discussion

Underscoring the idea that violence is a public health issue, this study found that violence prevention programs can reduce health care utilization. Such utilization by KP Health Plan members in the intervention schools decreased by 19%. School attendance was unaffected by the program, but the cumulative number of days of suspension decreased by 12% in the intervention schools while increasing by 25% in the control schools.

Extrapolating the change in mean number of health visits per member for the age cohort targeted by this intervention to the 34,000 KP San Diego Health Plan members in this age category would indicate a net savings of approximately 10,200 health visits per year. The incremental cost of the intervention per child was $15.10, whereas reducing the number of health visits saved $22.40 per child. The small sample size precludes any valid societal cost-benefit analysis, but the cumulative effects of the program--decreases in health care utilization and in disciplinary procedures--suggest that the program is fiscally sound and cost-effective. For these reasons--in addition to the power of theater as a teaching tool, demonstrator of social skills, and instrument of acculturation--now is the time to use theater for health promotion.

Acknowledgments

The Kaiser Permanente Garfield Memorial Fund provided research support.

Diana Petitti, MD, assisted with study design.

References

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