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Prevention: developing a framework for conceptualizing and evaluating outcomes of preventive services for older people.

There is growing preoccupation among policy makers and commissioners in developing preventive strategies and services. There is simultaneous concern with evidence-based purchasing and provision, within health and social care. In social care the evidence base regarding prevention is neither extensive nor robust. As the review of recent policy documents indicates, the concept of prevention is extremely slippery. What preventive services are and whether they are effective depends on the specific policy context, the overall service objectives and the perspective on outcomes adopted (user, carer, professional, service). Focusing on older people, the paper seeks a way through the confusion, locating prevention within a theoretical model of successful ageing. This conceptualizes ageing as involving adaptation to the changing balance between gains and losses over the life course. Successful ageing is perceived as the attainment of valued goals, the minimisation of losses and maximization of gains through the linked processes of selective compensation and optimisation. The paper then identifies necessary elaborations of the model to take into account the wider cultural and socio-economic context. This shapes and constrains the goals pursued and the resources available in adopting particular adaptation strategies. Within this model, preventive services may be conceived as resources to be drawn upon to support compensatory strategies. Similarly, outcomes and effectiveness of services may be evaluated in terms of whether they facilitate/allow older people to achieve valued goals. In developing and evaluating preventive services in social care the question of interest is reformulated: what contribution do specific services make in optimising gains and compensating for the losses that accompany ageing? This framework is explored in respect of two substantive areas ripe for secondary prevention services and strategies - bereavement and instrumental support in the home.