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Appendix Community Settings and Channels for Prevention Practitioners and researchers in a variety of fields, from agricultural extension to public health, have come to think that prevention planners and practitioners should work from a series of fundamental propositions: (1) Begin from a base of community ownership of the problems and the solu- tions; (2) plan thoroughly using relevant theory, data, and local experience as bases for program decisions; (3) know what types of interventions are most acceptable and feasible to implement (in the absence of certainty about what is most effective) for specific populations and circumstances; (4J have an organizational and advocacy plan to orchestrate multiple intervention strategies into a complementary, cohesive program; and (5) obtain feedback and evaluation of progress as the program proceeds (Abrams et al., 1986; Bracht, 1990; Breckon et al., 1989; Dignan and Carr, 1986; Green and Kreuter, 1991~. These general propositions have had sufficient testing in a number of areas to be called "principles of practice" (Bracht and Kingsbury, 1990~. Whether they have sufficient research support to be considered theoretical propositions, however, is debated by experienced practitioners and research scientists (Glanz et al., 1990; Thompson and Kinne, 1990~. The first prin- ciple, for example, would qualify as a corollary of the theory of participa- tion. That is, cumulative research in educational psychology and various applied fields demonstrates with some consistency that cognitive, affective, and behavioral changes in learners or clients are greater in response to interventions when the subjects engage actively rather than passively, agree on the purpose of the change (especially when convinced that the purpose 119
120 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? serves their own goals, relates to their own values, and meets their own perceived needs), control the pace and content of the intervention, monitor results, and obtain direct and immediate feedback on their own performance. These highly generalizable tenets of the theory of participation apply in classroom, worksite, recreational, and clinical settings as well as in commu- nity-wide interventions (Bracht and Kingsbury, 1990; Green, 1986; Hunt, 1990; Minkler, 1990~. The relevance and application of these broad generalizations to drug abuse prevention bear further study. The principles tend to be applied, sometimes intuitively, by drug abuse prevention planners and practitioners, but their analysis by researchers has been unsystematic (Holder and Giesbrecht, 1989; Room, 19891. Drug abuse prevention research could learn from and contribute much to the evolving body of prevention research on health and human services. This appendix examines the prevention literature on a vari- ety of health and human service fields related to drug abuse. Our purpose is to draw implications whenever possible between other bodies of prevention research and the prospects for drug abuse prevention through various com- munity-based channels and settings. Promising community-wide interven- tions are examined first, followed by specific settings within communities including schools, families, work sites, and medical care settings. We seek, in particular, to identify gaps in knowledge that could be most fruitfully addressed by drug abuse prevention research. COMMUNITY INTERVENTIONS We distinguish here between community interventions and interven- tions in communities. The differences are two: (1) the comparative magni- tude and scope of the undertaking, as determined by the size and diversity of the group or population for whom the program is intended and (2) the number of organizations and levels of organization involved. Defining Community The term community has various meanings. In the context of profes- sional practice or research, it is necessary to choose an explicit, operational definition. In this discussion, community is defined in structural and func- tional terms. Structurally, a community is an area with geographic and often political boundaries that are demarcated as a county, a metropolitan area, a city, a township, a neighborhood, or a block (Holder and Giesbrecht, 1989~. Functionally, a community is a place where "members have a sense of identity and belonging, shared values, norms, communication, and help- ing patterns" (Israel, 1985:72~. A "sense of community" is defined and developed as a concept relevant
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 121 to community organization by various investigators (Allen and Allen, 1990; Chavis et al., 1986; Chavis and Wandersman, 1990; McMillan and Chavis, 1986~. Sense of community makes it possible to conceive of a community that crosses geographic boundaries and places. This shared sense of com- munity may unite individuals who are physically dispersed. It is also quite possible to identify with multiple communities that may be physically bound, dispersed, or political in nature. Groups with lower socioeconomic stand- ings, however, are difficult to characterize as to the dominant source of their sense of community. A better understanding of the reference commu- nities of poor and alienated populations may hold clues to the identification of some within them with drug cultures; this phenomenon deserves research attention, both from the standpoint of what causes people to lose their sense of identity with neighborhood communities and from the standpoint of how alternative cultures substitute for the geographic community as a source of social anchoring. Research on drug abuse prevention in schools often fails to take com- munity structure and dynamics into account. For example, the busing of students to some schools may produce a blended, ungeographically bounded community in the school or a melting pot of community cultures from distinct neighborhoods, each forming a distinct subculture within the school. Informal political forces often exert more influence on program imple- mentation than the formal political structures associated with official boundaries (Brown, 1984; Rothman and Brown, 19891. Ultimately, the geopolitical scope of a program will be determined by those working in it, guided (in the best case) by local individuals who know the community. The resources available to support the program within the community and from other levels (state or national) are also inportant. As noted in Chapter 1 of this report, disaggregation of community characteristics must be part of any analysis of a culturally diverse population. So too disaggregation of com- munity must also be part of the planning process for programs in order for them to adapt to cultural differences. Important to the development of drug abuse prevention is the dispersed "community of interest." National advocacy organizations such as the Smoking Control Advocacy Resource Center, Americans for Nonsmokers' Rights, Mothers Against Drunk Driving, the National Association of Prevention Professionals and Advocates all rely on a constituency of concerned citizens scattered around the country. Voluntary and professional associations that advocate and develop prevention initiatives through their networks of mem- bers and chapters distributed around the nation represent, in each case, a community of interest. Much of the discussion in this chapter is pertinent to these interest groups on state, national, or international scales (see Paehlke, 1989; Pertschuk and Erikson, 1987; Pertschuk and Schaetzel, 1989; Wallack, 1990).
22 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? Although the structural aspect of the definition of community limits activity to a local focus, local community programs are generally coordi- nated with larger state and national prevention endeavors. Many programs conceived at the national and state levels are designed to be deployed as local community programs. How well these "packaged" community pro- grams can be replicated effectively in multiple, culturally differentiated com- munities is a question deserving research attention by state and national organizations that sponsor the programs. In summary, a clear definition of the community involved sets the stage for any research endeavor attempting to understand drug prevention inter- ventions. The meaning and generalizability of such research hinges on which community features are common to other communities and whether these common features are instrumental to the effectiveness of interventions to prevent drug abuse. Communities and Mass Media Community-based interventions can be distinguished from interventions carried out at the state or national levels, yet regional- and national-level campaigns can also have a complementary and supportive role in local efforts. (For descriptions of national campaigns sponsored by Public Health Service agencies, including the Office of Substance Abuse Prevention, see Office of Disease Prevention and Health Promotion, 1990.) Where appro- priate and feasible, community-based programs try to coordinate their inter- ventions with larger population campaigns to obtain the media benefits as well as other resources that support the larger effort (e.g., Davis and Iverson, 1984; Maloney and Hersey, 1984; Samuels, 1990~. Most of the methods used in community media initiatives in prevention programs can be adapted to the state and national levels (see Arkin, 1990; Green et al., 1984; Shoe- maker, 1989; Wallack and Atkin, 1990~. The role of the media in communicating substance abuse messages across community boundaries and the effects of bypassing community structures to reach individuals directly, without actively engaging community institu- tions (e.g., schools, churches, parents), need further research. Both drug- promoting messages (e.g., alcohol advertising, music video entertainment) and antidrug messages (e.g., public service ads) communicated through mass media often reach individuals without institutional screening at the local level (American Medical Association, 1986; Atkin, 1987; 1990; McDonald and Estep, 1985; Wallack et al., 1987~. Research is needed not only on the national media depictions of use, but also on the role of community institu- tions schools, families, churches, and agencies- in buffering or building on these mass communications. Besides the mass communications that emanate from outside the com
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 123 munity, much use is made in community-wide prevention programs of lo- cally produced or adapted mass communications and local media outlets such as local radio, television, newspapers, and direct mail. These re- sources are considered in the context of other community interventions in the discussion that follows. THE LOGIC OF COMMUNITY-WIDE INTERVENTIONS Much of the prevention research on drug use has been in the specific settings of schools or institutions in contact with high-risk populations, such as juvenile justice divisions. These settings concentrate prevention resources and tailor prevention interventions, affording greater experimen- tal control, greater homogeneity of subject populations, and more certain generalizability of results to similar settings. Nevertheless, there is reason to redirect some program and research efforts toward more community-wide interventions and studies. Encouraging results from several sources have fostered growing sophis- tication and larger numbers of community-wide health promotion and dis- ease prevention programs: the large-scale family planning and immuniza- tion programs reported in the 1960s and early 1970s (Cuca and Pierce, 1977; Green and McAlister, 1984~; antismoking campaigns (Flay, 1987a,b; Warner and Murt, 1983~; and cardiovascular and cancer community preven- tion trials initiated in the late 1970s and early 1980s (Farquhar et al., 1990; Farquhar et al., 1983; Lasater et al., 1984; Nutbeam and Catford, 1987; Puska et al., 1985~. The environmental movement has sought a similar level of community-wide activity around issues such as recycling, toxic waste disposal, water conservation, and van pooling (Freudenberg, 1984; Paehlke, 1989; Spretnak and Capra, 1984~. The AIDS epidemic, infection with the HIV virus, and teenage pregnancies have revived a parallel and converging interest in community approaches to health education (Becker and Joseph, 1988; Coates et al., 1988; Leviton and Valdiser, 1990; Winett et al., 1990; Markland and Vincent, 1990; McCoy et al., 1990; Ostrow, 1985; Patton, 1985; Williams, 1986~. The community-wide approach has the po- tential of complementing and supporting institution-based programs in three ways: epidemiologic, social psychological, and economical. Epidemiologic Dimensions Most community-wide demonstrations are designed to produce small changes in large populations. Numerically speaking, a small percentage change in an entire population would yield greater public health benefits than would a comparable level of effort aimed exclusively at the 10 percent of the population deemed to be at highest risk. More people gain a little,
24 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? and a little prevention goes a long way relative to a lot of cure, especially when the disease or condition has a contagion aspect to it. Public health analysts provide the epidemiologic and sociological arithmetic justifying these population approaches (Blackburn, 1987; Chamberlin, 1988; Farquhar, 1978; Kottke et al., 1985~. Whether these calculations apply when the condition to be prevented is drug use deserves similar epidemiological study. The following studies are examples of how the arithmetic works when the changes sought are behavioral and the outcomes sought are chronic disease reductions. In a county-wide cardiovascular prevention project in North Karelia, Finland, only 2 percent of the target population lost weight, but this amounted to 60,000 people, far more than could have been reached through doctors' offices (Puska et al., 1981~. The Australian Quit For Life media campaign produced a mere 2.8 percent reduction in smoking prevalence (Dwyer et al., 1986; Pierce et al., 1990), which would be considered a failure by targeted smoking cessation program standards (Lando et al., 1990a,b), but it amounted to 83,000 fewer smokers in Sydney. A television and community organiza- tion effort to support smokers' quitting in Toronto yielded a 2.9 percent reduction in smoking prevalence, which translated to 8,800 fewer smokers than expected from extrapolated trends in Canada (Miller and Naegele' 1987~. The scattered and sporadic but relentless antismoking efforts in the United States between 1964 and 1978 produced a net annual reduction in smoking prevalence of only 1 percent, but this produced in turn an estimated 200,000 fewer premature smoking-related deaths, with many more expected to be avoided as former smokers survive through the 1980s and 1990s (Warner and Murt, 1983~. Unlike the programs discussed in Chapters 2 and 3 de- signed to afffect young, early-phase smokers, these campaigns were ad- dressed primarily to adults with long-established patterns of dependent smoking behavior. These epidemiologic examples of the extensive, though proportionately small, benefits of community-wide interventions relative to the more effec- tive but limited range of targeted, intensive, institutionally based interven- tions (Schorr, 1989) argue for a place at the prevention table for community approaches to drug use prevention. Two questions arise, however, in trans- lating the epidemiologic case from disease prevention and health promotion specifically to drug use prevention research. One is whether the prevention of conditions or behaviors that pertain to whole populations, such as the risk of heart disease and related eating behavior, apply in the same ways to prevention of illicit drug abuse prevention. They do apply clearly in the intermediate case of smoking. The other is whether the health implications of small changes in large populations that make the epidemiologic case for health promotion in relation to heart disease and cancer prevention apply to drug use prevention.
COMMUNI7 Y SETTINGS AND CHANNELS FOR PREVENTION Social-Psychological Dimensions 125 On the basis of their review of decades of research and experience on sexually transmitted disease control, Solomon and DeJong (1986:314) con- clude: "More than any other recommendation, we urge that AIDS risk- reduction strategies focus on establishing a social climate in which people feel that it is the norm and not the exception to adopt AIDS risk-reduction behavior." This concept of building a social norm for behavior conducive to health lies at the heart of the social-psychological justification for com- munity approaches to prevention (swore and Kreuter, 1980; Green, 1970a,b; Green and McAlister, 1984~. Clearly the antismoking initiatives have suc- ceeded in doing just that (Chandler, 1986; Fiore et al., 1989; Flay, 1987a,b; McGinnis et al., 1987; Pierce et al., 1989~; designated drivers rather than drinking and driving appear to be making similar strides in becoming a norm (Jernigan and Mosher, 1987; Wallack, 19849; low fat eating has begun to take on the markings of a social norm, at least in more affluent communi- ties and their upscale restaurants (Block et al., 1988; National Restaurant Association, 1989; Popkin et al., 1989; Food Marketing Institute, 1989~. The task in these areas, as may be true of drug prevention, appears to be to ensure that such norms diffuse to all segments of the community. This will almost certainly require more targeted research and program efforts in high- risk subpopulations. However, the social-psychological case does not require choosing be- tween community-wide approaches and targeted approaches. The concept instead is that these approaches may be mutually reinforcing in their effects. Social marketing and classroom learning experience indicate that targeting or "market segmentation" ensures more tailored, relevant, and effective teaching of persuasive messages to individuals (Kotler and Roberto, 1989; Manoff, 1985~. But an individual can be powerfully predisposed to change his or her own perception that others have made the change successfully (role models) and with satisfaction (vicarious reinforcement). Furthermore, the individual making the change can be enabled by imitation and by help from friends, and reinforced by the approval of significant others, if enough so- cial change is taking place around the individual, i.e., if other people and environmental circumstances support the change in the same period of time. This is a fundamental thesis of social learning theory (Bandura, 1986; Clark, 1987; Parcel and Baranowski, 1981~. Employing a combination of targeted and community approaches rec- ognizes the reciprocity between individuals and environments and between individualized approaches and system approaches. (For critical reviews of debates that set these approaches against each other rather than on a comple- mentary basis, see Green and Raeburn, 1988; Minkler, 1989; Rimer, 1990; Simons-Morton et al., 1988.) Those undertaking community approaches
26 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? count on individual innovators to blaze a trail, and also try to reinforce the innovative behavior and reach others by building greater environmental and normative supports. Ordinances to control smoking in public places, for example, give support to those who have quit smoking and protect them from exposure to the smoking behavior of others while also pushing others to quit. However, research is needed on the potential backlash in some seg- ments of the community when norms are developed through coercive means without effective public education, as when panic about drugs results in massively increased police and other control activity in a community. Such activity alters the social processes in drug-using subcultures (Young, 1981; Courtwright et al., 1989), hardens the boundaries of the subcultural group, and may generate new problems, such as increasingly violent drug deal- ~ng. One theoretical rationale for community programs is to provide envi ronmental and social supports for change through policies and mass media. Another is to coordinate institutional interventions to strengthen psycho- logical readiness or resistance to drugs, through families, schools, work sites, and health care settings, in which more individualized communica- tions can be organized. Policies and mass media, in the long term, help shape psychological readiness, and institutional settings provide ideal op- portunities for social and environmental supports for change. In short, the combination of interventions at multiple levels should enhance the diffusion throughout the community necessary to reach indirectly those who are not reached personally directly. Economic Dimensions A major barrier to reaching the more economically disadvantaged seg- ments of the population is often the paucity of financial resources available in the poorer parts of the community, where a multitude of problems are concentrated (Oberschall, 1973~. Although the drug abuse problem may affect larger numbers of middle-income and more affluent people than poor people, the media tend to portray it as a problem of the poor. Once the parents of adolescents in the middle-income and affluent segments of the community recognize that the problem may well affect their own children, they are more likely to support agencies and programs that reach out to the whole community to prevent the problem. This is the so-called agenda- setting function of mass media and community organization (Gaziano, 1985; Protess et al., 1985; Shaw and McCombs, 1989~. Economic and other motives that might underlie public responses to drug problems, such as those revealed in studies of voting behavior and support for school initia- tives, need greater attention from the drug abuse prevention research field if
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 127 school-based programs are to have the support they need from the commu- nity to succeed when the researchers are gone. THE SIZE, SCOPE, AND COMPLEXITY OF COMMUNITY INTERVENTIONS Community interventions are more than the sum of multiple interven- tions in the community. The synergism and leverage sought with the coop- eration of several organizations, each with a constituency and a distinct set of resources, requires measures and criteria of process and impact that dif- fer qualitatively as well as quantitatively from those used in research on interventions in the community. Community-wide interventions require that the planners have the staff (or at least committed volunteers), resources, and political influence to deliver on the task of involving several sectors of the community, including the major channels of mass communication. Few agencies have the personnel and purview to take on community-wide pro- grams by themselves, and much of the change required in complex issues such as drug abuse prevention calls for broad political support and consen- sus. For these reasons, community coalitions have become the mainstay of most health promotion/disease prevention programs. Despite their popular- ity, there has been little formal research even to describe the array of coali- tion types (Couto, 1990), much less to evaluate their efficacy (Feighery and Rogers, 1990~. Systematic case studies followed by comparative analyses of different types of coalitions and their effectiveness are very much in order. From the standpoint of evaluation research, determining the size and scope of community-wide prevention programs depends on having the re- sources and capacity to collect and analyze the population-based data nec- essary to detect changes over time. Research is needed on the development of efficient means of data collection and analysis on community norms and behavior related to drug abuse. The individually small but widespread changes sought by community health programs apply to the majority of the population. Interventions within a community seek more intensive or profound change in a limited subpopulation, usually within or from a specific community site such as the workplace, hospital, clinic, or school. Health care workers using the latter approach can take advantage of the strong reinforcement provided by the group dynamics within institutions and the interpersonal channels of com- munication. Such interpersonal and small-group interventions are more common, more manageable, and probably better understood than commu- nity-wide programs. Institution-based programs lend themselves better to systematic, controlled research, hence their stronger research base. But community-wide programs have greater potential for making significant popu
28 PREVENTING DRUG ABUSE: WHATDOWE KNOW? ration changes primarily as a result of reaching larger numbers of people through mass media and multiple channels of communication, building wide- spreao normative, economic, and political support for the changes, and pos- sibly stimulating change in a community's policies and social fabric (Bracht, 1990; Christenson et al., 1989; Green and McAlister, 1984~. Bigger programs are not necessarily better programs. In fact, site- or area-specific health promotion interventions carried out within communi- ties, such as demonstration programs in schools, have provided the stron- gest evidence of short-term impact and flexibility to adapt to the special needs of subpopulations and individuals, and they can serve as models and inspirations for broader community change by other organizations that will emulate them (Carlaw et al., 1984; Green et al., 1991; Orlandi et al., 19901. As more organizations adopt or extend components of the program, a multi- plier effect gets under way, with the funded demonstration projects being emulated by others without external funding (Kreuter et al., 1982~. Re- search on examples of the diffusion or multiplier effect of drug abuse pre- vention projects should be possible, considering, for example, the number of community demonstration projects being funded by the Center for Sub- stance Abuse Prevention grants. APPROACHES TO COMMUNITY-BASED RESEARCH Community Participation The larger the community, the greater will be the number of representa- tives of subcommunities and cooperating organizations engaged in the plan- ning for community-wide interventions. Early involvement of community members in identifying their own needs, setting their own priorities, and planning their own programs is in itself an intervention. It provides the opportunity for ownership that can lead to a sense of empowerment and self-determination. Gaining broad-based community participation for the federally funded, large-scale research and demonstration efforts in prevention, however, has been problematic. Up-front community initiation and participation in the pioneering community intervention trials in family planning, heart disease prevention, and cancer control has been limited, for good reason. These large scientific studies were conceived and, for the most part, planned by public health officials at the federal level and professors who received the research grants or contracts. Efforts to engage the community typically occurred after the planning had been started, if not completed. The protocol was approved by a national peer review panel and the grant approved by a federal agency. The active participation of the community could usually come only after the grant was in hand. Asking communities and organiza
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 129 lions to implement programs planned elsewhere and evaluated on someone else's terms might gain some followers, but the duration of their commit- ment may be only for "as long as the money lasts." Researchers working on large community interventions face a paradox. They must design the proposals for scientific trials and rigorously evaluated demonstrations according to guidelines of the federal government. Commu- nity participation thus begins when key people in the target communities are informed of the researcher's intent to apply for the grant and their willingness to cooperate is needed for the application. This form of com- munity participation may be criticized as too little, too late. If community leaders are invited to participate in the implementation but not in the policy and planning stages, they may feel they are being used as free labor for university-initiated projects. This dilemma reflects an inability to design unbi- ased scientific tests of community interventions without damaging a variable (active community participation) that is likely to be essential for successful community structural and cultural change, as well as behavioral change in individuals (Green, 1977; Holder and Giesbrecht, 1989~. Very early activation of the community in these instances may falsely raise community hopes and expectations should funding not be secured. Nevertheless, some communi- ties go on from this point to develop their own programs without external funding. Pentz and her colleagues (1986) have attempted (with mixed suc- cess) to address some of these issues in balancing program and research integrity in Project STAR, the Midwestern Prevention Project. The scientific benefits of the early community studies may have justi- fied their restraints on early and active participation of community mem- bers. The evidence pointing to the benefits of community participation (Bracht and Kingsbury, 1990; Green, 1986; Hunt, 1990; Minkler, 1990) now demands a continuing search for funding mechanisms between levels of government and procedures of grant making that provide for greater com- munity involvement (Green, 1986; Williams, 1990~. Program Implementation and Evaluation Much of the success or failure of programs imitating or attempting to replicate previously demonstrated and evaluated prevention programs can be attributed to the quality and performance of management, personnel, and resources deployed to implement the program. A growing body of literature on the evaluation of implementation, or process evaluation, has developed in recent years (King et al., 1987; Ottoson and Green, 1987, Reid and Hanrahan, 1988~. Considering the wide variety of personnel implementing drug abuse prevention programs as well as the rapid development of new strategies, further research on implementation problems and evaluations of implementation must be supported.
130 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? Training and Evaluation The Office of Substance Abuse Prevention spends some $30 million annually on training. Upgrading the skills of personnel working in drug abuse prevention is necessitated by the fast-breaking results of research and evaluation on new innovations in prevention programming. Training, like program implementation, has been relatively neglected as an object of re- search and evaluation in all fields of prevention until recent years, but a growing literature is taking shape (Easterby-Smith, 1986; Fitz-enz, 1984; Phillips, 1983; Staropoli and Waltz, 1978~. Most of the published work on the evaluation of training has been in the form of exhortations to practitio- ners to do more of it and manuals to help them do so. Serious development of measurement tools and standardization of criteria for the evaluation of training needs support (Battista and Mickalide, 1990; Brinkerhoff, 1987~. Diffusion Research Once research indicates the feasibility, effectiveness, and generalizability of specific interventions in specific settings, the next level of research and evaluation should assess ways to facilitate the diffusion of these innovative strategies. The National Cancer Institute, the National Institute for Dental Research, and the National Heart, Lung, and Blood Institute are now sup- porting such diffusion research on the site-specific (school, clinical, and workplace) adoption of interventions for prevention that have been tested in previous field or clinical trials (Basch, 1984; Basch et al., 1986; Brunk and Goeppinger, 1990; Coombs et al., 1981; Orlandi, 1986; Orlandi et al., 1990; Parcel et al., 1989a,b; Portnoy et al., 1989; Scheirer, 1990~. Similar re- search on the diffusion of drug abuse prevention innovations is likely to yield similar conclusions about the correlates of successful diffusion and adoption, but the research needs to be sponsored and completed before this assumption can be accepted. Community-Wide Trials The need for developmental and outcome studies on the proliferating community-wide programs is urgent; these projects are based on the logic and theoretical foundations outlined above, but their efficacy in preventing drug abuse can only be inferred at this time from a handful of studies in family planning, immunization, smoking, and cardiovascular risk reduction. The closest a National Institute on Drug Abuse (NIDA) project has come to verifying community organization models derived from other fields is in the Midwestern Prevention Project (Pentz, 1986; Pentz et al., 19864; the data reported to date, however, are based only on the school-based component of the program in one city, with parental involvement and mass media cover
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 131 age (Pentz et al., 1989~. NIDA might have tested the viability and efficacy of community coalitions for drug abuse prevention before they were an- nounced as a required component of grants from the Department of Health and Human Services. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) sponsored a conference on Methodological Issues in Community Prevention Trials for Alcohol Problems at the University of California, Berkeley, in December 1989 (Holder, 1991~. Drawing on the experience of the recently completed community trials in cardiovascular risk reduction funded by the National Heart, Lung, and Blood Institute, the papers presented at that conference brought out many of the same methodological differences and similarities that face research on community-wide strategies for drug abuse prevention. SCHOOL AS A SETTING FOR INTERVENTION Most of the drug abuse prevention research, as seen in the chapters of this report, has been conducted in school settings. We believe the issues in the use of the school as a setting for drug abuse prevention center as much on the conflict of purposes and the proper use and preparation of teachers as on the specific content of methods of intervention. Drug abuse prevention in schools must depend for its administrative acceptance and support on the ability to demonstrate an impact on educational goals, not just on drug use or abuse. Purpose and Functions of School Health Programs Those concerned about drug abuse sometimes promote the health or social objectives of prevention without much apparent attention to the pri- orities of cooperating organizations. Nowhere do these differences between the perspectives of those representing different sectors clash more than in school health. From the health perspective, schools represent a valuable resource for drug abuse prevention, but schools are relatively independent of the health and social service sectors. Every school day nearly 47 million students attend elementary and sec- ondary schools in the United States; about 6 million professional and other workers staff those schools. (American Council of Life Insurance, 1985~. (The numbers and proportion of school-based staff is larger if one includes colleges, universities, and the rapidly growing number of preschool and day care centers. The principles discussed here apply similarly in college drug abuse prevention programs.) Schools thus constitute the center of activity for nearly one-fifth of the U.S. population. Orchestrated drug abuse pre- vention in schools might constitute society's most cost-effective prevention strategy (Carnegie Council on Adolescent Development, 1989~.
32 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? From the educator's perspective the school has a different set of priori- ties, and many believe its educational role in society should not be compro- mised in the pursuit of health or drug abuse prevention objectives. Some argue that even behavioral objectives, including health behavior, have no place in the school's mission because they detract from the primary objec- tives of learning critical thinking and reasoning (Resnick, 1987~. The most acceptable justification of drug abuse prevention and health services in the school has been to ensure that students would be kept healthy enough and attentive enough to be able to attend and benefit from school activities (Kolbe et al., 1986~. School personnel need the cooperation and resources of community agencies and media in support of the school's mission, especially when that mission is expanded to include purposes such as drug abuse prevention that go beyond the school's educational mandate. Students spend one-third of their work-week hours in school, but they spend more than two-thirds of total hours, counting weekends, holidays, and summer vacations, outside the school. Furthermore, some of the children and youth who need help with drug abuse prevention the most have dropped out of school or have such high absenteeism that they will not be reached by school programs. Schools alone cannot solve society's health and social problems. They tend to sidestep the responsibility to address problems such as drug abuse as long as they perceive their own educational role as threatened by the si- phoning of the school's resources into areas they consider tangential to their basic educational mission (Kolbe and Iverson, 1983~. The educational priorities of schools become even more compelling for school personnel when budgets are tight (as they have been for decades) and when parents and employers become concerned about the decline in student performance on standardized tests in reading, writing, and arith- metic. The back-to-basics pressures on schools tend to push health educa- tion, physical education, and even school nursing services into the back- ground, signaling a perception of their diminished status (Allanson, 1978; Hertel, 1982; Kolbe, 19821. Yet there is growing evidence of the benefits of these elements and services for school-age children in reducing absentee- ism, increasing average daily attendance, improving attentiveness, reducing vandalism, and other aspects of the school's mission (Kolbe et al., 1986~. Components of School Health The basic structure of school health programs as reflected in the litera- ture has remained relatively unchanged for over 50 years. It consists of three interdependent components: (1) health instruction, (2) school health services, and (3) a healthful school environment (Cornacchia et al., 1988; Creswell and Newman, 1989; Pollock and Middleton, 1989~.
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 133 Comprehensive school health refers to these multiple components of the school health program within the school as well as the active involvement of parents and the community in the health affairs of the school and on behalf of the health of school-age children (Becker et al., 1989; Perry et al., 1988~. Comprehensive school health education refers to an instructional program that provides for an integrated, K-12 curriculum covering the full range of health topics and problems. Such comprehensive approaches have gained considerable credence and acceptability with school administrators and teachers in preference to "disease-of-the-year" approaches that have tended to create curricular chaos as federal and state categorical funding changes too frequently to permit an integrated program. Add to this the virtual barrage of categorical curricula that each voluntary association seeks to introduce into the school and one can appreciate the school's strong preference for a single comprehensive approach. A new generation of school-based studies on drug abuse prevention might be in order. Such research could examine the role of drug topics within the context of the comprehensive school health curriculum; the role of the curriculum (instructional component) within the context of school health services and environment; and the role of the school within the con- text of a network of other community resources and channels of communi- cation to determine how the school programs in drug abuse prevention comple- ment other community efforts. Evaluation of School Health Education After decades of basing support for comprehensive school health on learning principles and research evidence borrowed from other fields, con- temporary school health literature is suddenly endowed with rigorous evalu- ations of well-designed school health and school health education programs. The most sweeping evidence, contributed to the literature in the 1980S? was the nationwide evaluation of the comprehensive School Health Curriculum Project. From a handful of small-scale studies conducted before 1980 with limited controls (usually pretest-posttest designs) and with little behavioral impact measured (usually knowledge and attitude changes only see Green et al., 1980), the opportunity arose in 1981 to carry out a multisite random- ized evaluation of this project and several other health curricula with sup- port from the U.S. Office of Disease Prevention and Health Promotion and the Centers for Disease Control. The School Health Education Evaluation was a pioneering 3-year pro- spective study, involving 3O,000 students in grades 4-7 in 20 states. It revealed that students who were exposed to comprehensive school health education not only showed significant positive changes in their health-re- lated knowledge and attitudes, compared with students in matched schools
34 PREVENTING DR UG AB USE: WHAT DO WE KNOW? without such exposure, but they were also considerably less likely to take up smoking. Especially relevant were those findings that clearly demon- strated that administrative support and teacher training were directly linked to the positive student outcomes detected, as were the cumulative number of hours of classroom time devoted to comprehensive school health education (Cornell et al., 1985; Connell and Turner, 1985; Cook and Walberg, 1985; Gunn et al., 1985; Olsen et al., 1985; Owen et al., 1985~. The National Institutes of Health has commissioned several panels of scientists to review what has been learned about school health education (e.g., Kreuter and Reagan, 1980; Newman, 1980; O'Rourke and Stone, 1980; Kolbe and Iverson, 1980; Kolbe et al., 1986~. In 1988, an expert advisory group convened by the National Cancer Institute (NCI) reviewed 20 years of research on school-based efforts to prevent tobacco use. The panel found nine areas with sufficient data or experience to reach preliminary conclu- sions and recommendations: program, impact, focus, context, length, ideal age for intervention, teacher training, program implementation, and the need for peer and parental involvement (Glynn, 1989, describes the 15 school- based smoking prevention studies supported by NCI; in the same issue, eight studies of smokeless tobacco prevention trials supported by NCI are described by Boyd and Glover, 1989; the American Cancer Society's and NCI's development and evaluation of a school nutrition and cancer educa- tion curriculum is described in Light and Contento, 1989~. The National Heart, Lung, and Blood Institute supported a variety of school-based research efforts, 10 of which are summarized in Table A.1 (Stone et al., 1989~. As the table indicates, these studies reflect diversity in the demographic characteristics of the populations studied, the risk factor focus, and the methods and channels of intervention. Several of the studies emphasized the importance of a planning model to complement and orga- nize specific theoretical models (Best, 1989~. As a result, this collection of studies placed rather strong emphasis on the home to address reinforcing factors in the social environment as a complement to school interventions. A panel convened by the Kaiser Family Foundation concluded that drug abuse prevention programs are likely be most effective when implemented in the context of comprehensive school health programs linked with com- munity health promotion programs (Flay, 1986; Pentz, 1986; Perry, 19861. The Family as a Channel The studies summarized in Table A.1 are identified as school-based studies, but 7 of the 10 use the strategy of linking home and school as mutually reinforcing settings for children's behavior. In the Nader et al. study (1989), the family is the primary locus or channel of change rather than the school and its environment, which serve a supportive role.
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 135 Efforts to expand the focus of school programs to place increasing emphasis on the home and family are supported by findings from a 1988 national school health education survey sponsored by the Metropolitan Life Foundation (1988~. The survey sampled over 4,000 students from 199 public schools and SOO randomly selected parents of children attending schools. Among other things, the survey revealed that, while the majority of both teachers and parents believe that parental involvement in children's health education would be of considerable help in encouraging good health habits for children, most parents (71 percent) report never getting involved in the process. Lack of parental involvement may in part explain why parents do not know the extent of drinking, smoking, or drug-taking by their children. Whereas 36 percent of the parents surveyed indicated that their child has had at least one alcoholic drink, 66 percent of the students said they had alcohol at least once or twice; only 14 percent of parents reported that their child had smoked a cigarette, whereas 41 percent of students said they had smoked; 5 percent of parents said that their child had used drugs, whereas 17 percent of students reported having used drugs. International investigators have also conducted studies that employ close collaboration among key institutions within the community and with the family. The North Karelia, Finland, Youth Project included modifications in the school diet, health screening, mass media, comprehensive school health education, and parental support to reduce the major risk factors for noncommunicable diseases. Findings after two years revealed decreases in smoking and alcohol use in the randomized intervention schools compared with eight randomized reference schools (Vartiainen et al., 1986~. The common denominators for these successful programs and others like them include: (1) a commitment to addressing specific problems or modifiable risk factors, often within the context of a comprehensive ap- proach and (2) the use of multiple intervention methods based on an assess- ment of the characteristics, needs, and interests of the target population and designed to reach the individual through multiple channels including media, institutions, and the individual's family and peer groups. Questions for further research to make these findings pertinent to drug abuse prevention are whether the behavioral changes with respect to to- bacco and alcohol, among others, respond to different interventions or dif- ferent channels of communication than do illicit drug behaviors; and whether these findings can be generalized to the ethnic and school dropout popula- tions of high-risk youth. In general, the preventive approaches that have been rigorously evaluated would require one-size-fits-all assumptions in order to be generalized to drug abusing and ethnic groups other than those in which they have been tested. Research on the relationships among prob- lem behaviors and preventive or risk-avoiding behaviors in children suggest a clustering of problem behaviors (Donovan and Jessor, 1985) and health
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138 PREVENTING DRUG ABUSE: WHATDO WE KNOW? related behaviors (Terre et al., 1990), but the clusters may vary with age. These findings make the assumption of the appropriateness of similar one- size-fits-all approaches partially supportable and partly questionable. THE WORKPLACE SETTING This report does not deal specifically with drug abuse prevention pro- grams in the workplace; a separate National Research Council committee is conducting a multidimensional study of workplace drug programs (National Research Council, 1993~. Nevertheless, as a potential channel of communi- cation on drug abuse prevention and a setting for related programs, the workplace merits some mention here. Workplaces are to adults as schools are to children: a place where they spend many of their waking hours, where group affiliations are shaped, where rewards are received for perfor- mance and productivity. It is also a place where many adult users maintain access to drugs and where strong leverage can be exercised through the threat of job loss. About three-fourths of adult men (age 16 and over) and over half of adult women in the United States are in the labor force (Bureau of the Census, 1989~. The increase in the female work force participation rate, especially working mothers, is reshaping the attitudes of employers toward employee benefits and working conditions. The workplace has replaced the neighborhood as the community of reference and social identity for many urban and suburban North Americans and Europeans (see, for example, Duhl, 1986; Glynn, 1981; Green, 1990; Riger and Lavraka, 19811. These demographic and social trends, combined with the pervasive in- fluence of occupational environments on adult health, quality of life, behav- ior and lifestyle, make work sites logical settings for preventive approaches to drug abuse. As with other settings, the example of other health promo- tion initiatives provides hypotheses for research and potential models for drug abuse prevention. Yet, more than other settings, workplaces have failed to incorporate drug abuse prevention in their health promotion programs. Based on sec- ondary analyses of a survey sponsored by NIDA, Cook and Harrell (1987:358) concluded: If drug abuse prevention is to be found in industry, one might expect to find it within the growing number of health promotion programs in the workplace, programs that emphasize the development of healthful practic- es through preventive means. Yet an examination of even the most com- prehensive health promotion programs (e.g. the programs at Johnson and Johnson, Control Data and AT&T), reveals that drug and alcohol preven- tion is not a part of these efforts.
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 139 Given this paucity of substance abuse prevention in the context of pro- liferating workplace health promotion programs, a brief look at the research on industry incentives for adopting health promotion programs may be in- structive. American business and industry took a fresh look at health pro- motion and disease prevention in the late 1970s as they faced the opening waves of alarming increases in the cost of medical care and insurance pre- miums for their employees (Collings, 1982~. In 1990, employers paid $186.2 billion or approximately 29 percent of all expenditures for personal health care services and supplies in the United States (Levis and Cowan, 1991~. Employers began to initiate health promotion programs based on a growing awareness of their potential health and economic benefits (Fielding, 1982; Fielding and Breslow, 1983; Parkinson and Associates, 1982~. Through repeated exposures to health messages via a myriad of formal and informal communication channels, the general public, including employers, began to see the relevance of the information confirming the link between health and factors they had the power to change. Although industry has responded with substantial commitments to new initiatives in workplace health promotion, the drug abuse issue has been addressed almost entirely within a treatment (employee assistance program) and enforcement (drug testing) framework rather than one of prevention. The health promotion programs themselves, especially the fitness and stress management programs, can be seen as primary prevention of drug abuse. Evaluation of these and other health promotion and employee assistance programs, based on a survey of 550 corporations (Katzman and Smith, 1989), has been extremely limited. Only 41 out of the 98 respondent firms reported that they were currently evaluating their programs, and most of these were using nonexperimental methods. Workplace health promotion appears to be today about where school health education was in 1980 with respect to rigor of research evaluation. Considering their potential for ef- fective drug abuse prevention, workplace programs deserve much more re- search attention than they have been given. THE HEALTH CARE SETTING As we have seen, considerable attention has been directed to drug abuse preventive interventions delivered in the school setting, usually by teachers, sometimes supplemented by peers of the students receiving the instruction. Research on drug use prevention in the school setting has overshadowed the limited prevention research in medical care settings. This setting, however, has had a lively development of research on interventions to prevent other problems besides illegal drug use (Cohen, 1979; Haynes et al., 1979; Lawrence, 1990; Matarazzo et al., 1984; Mechanic, 1983; Mullen and Zapka, 1982~.
140 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? In many communities, health care professionals, particularly physicians, are relied on as the local experts on the abuse of alcohol and drugs; others, however nurses, pharmacists, dentists, and other professionals offer equally attractive settings and channels through which to reach people at risk of drug abuse and to deliver preventive interventions. The medical, dental, nursing, or pharmaceutical setting has the poten- tial to provide prevention of substance abuse through patient counseling on the hazards of drugs; this is most likely to occur when a problem already appears to be present. Very little research on primary prevention counseling on drug abuse has been carried out in such settings (U.S. Preventive Ser- vices Task Force, 1989~. One criterion that should be used in determining who will deliver what preventive interventions and what settings deserve greater research focus is the potential coverage of segments of the population most needing the inter- vention. A second criterion is available time to deliver the intervention. A third criterion is credibility with the recipients. Dentists and dental offices, for example, meet all three criteria of po- tential coverage, available time, and credibility. Dentists have credibility within communities as health professionals. They spend substantial amounts of time with their patients; a normal office visit includes at least 30 minutes with the dentist and often an additional 30 minutes with a dental hygienist. Dentists are less specialized and more prevention-oriented than physicians and see their patients on a more consistent schedule; 63 percent of Ameri- cans report at least one visit with their dentist each year, and the annual number of visits to the dentist per patient averages 2. Of greater signifi- cance from a prevention perspective, dentists often treat entire families rather than isolated and independent individuals. Dental offices are good settings for drug abuse prevention because cigarettes, smokeless tobacco products, and other drugs that are smoked (e.g., mari- juana, cocaine) can be readily detected. The first evidence of use of these products by young people who would not admit their use may be in the oral cavity. The oral tissue is assaulted by both the hot smoke as well as the particulate matter in these drug delivery systems. In the case of smokeless tobacco, there are exceedingly high levels of carcinogenic nitrosomines in each package. Dentists closely examine the affected oral tissues and can readily detect the effects of use with normal observations (Greene et al., 19901. The hygienist can be trained to provide a booster to the intervention provided by the dentist as well as supplemental skill training for maintain- ing healthy oral tissue. A particular category accessible through health care settings are people who medicate themselves by taking drugs for an illness, who risk making a variety of mistakes, including use of an inappropriate drug, the wrong dos- age of the right drug, or the right drug at the wrong time. The most blatant
COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 141 form of drug abuse in this category is self-administration of larger doses of psychotropic drugs than prescribed and continued use beyond the prescribed period. Public education through nonmedical channels can reach most con- sumers to warn them about these potential hazards (National Research Council, 1989~. Research on these aspects of drug abuse prevention warrant particu- lar attention considering the number of people at risk. SUMMARY Much has been published from the extensive research on selective use of various settings and channels for prevention in areas other than drug abuse. The development of drug abuse prevention research need not repeat all of these studies to ensure that their results are applicable to the specific problems of preventing drug abuse. Many of the research furrows plowed by investigators in family planning, communicable disease control, chronic disease control, and alcohol abuse prevention have proved to be unfruitful and so need not be repeated with drug abuse prevention. But a more sys- tematic examination of the commonalities and differences between drug abuse prevention programs and those of other areas would advance the field of drug abuse prevention more rapidly than an isolated research agenda that seeks to build only on prior research within the sphere of drug abuse etiol- ogy and prevention programs. Most of the prevention research, in all but the school setting, has been in fields other than drug abuse. Within the schools, drug abuse prevention research would do well to link its program innovations and trials with more comprehensive curricula and school-community efforts. Those related to smoking prevention, teenage pregnancy prevention, and dropout prevention share similar methods and goals. School administrators will be more likely to adopt and maintain a curriculum that covers all of these problems com- prehensively than to have to construct each element individually. This integrative approach is already working for other areas of school education. Community-wide programs that include mass media and multiple set- tings have been relatively neglected as an object of systematic research in drug abuse. Other fields, particularly cardiovascular disease prevention, have much to offer from their extensive community trials. Two main themes stand out from the review undertaken in this appen- dix. First, it is critical to learn what constitutes the communities that are relevant to drug abuse prevention. What normative symbols, practices, events, and institutions do those at risk, and those who can influence them, identify with and respond to? How do drug-specific norms and behaviors dovetail with other health norms and behaviors? These questions are par- ticularly salient in low-income areas where assumptions that are built into public programs assumptions about family stability and support, member
42 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? ship in voluntary associations, literacy, commitments to core institutions, levels of safety-become uncertain. Richly "rained, systematic community studies using qualitative and quantitative methods were at one time a thriv- ing research enterprise that contributed to the formation of public policies on health and welfare and the shaping of specific programs to carry out public purposes, neighborhood by neighborhood. NIDA is not in a position to support a study of every community in the country, nor are the research resources available for this. NIDA is, how- ever, in a position to launch a strategic community research initiative: a research program to develop in a significant number of locations compre- hensive assays of community norms, identity, structure, and potentials for prevention coalition-building, based on the presence, absence, or levels of effectiveness of key services and institutions including schools, workplaces, and health care settings that can serve as platforms for sustained preven- tion efforts. Such study sites can become laboratories for developing com- munity models and testing study methodologies that may be practicable for every locality to use. The urgency of the drug problem in U.S. policy has driven many new drug abuse prevention programs into the field without much research. This has forced the recognition that some of the interventions and their specifica- tions rest on assumptions of efficacy and effectiveness based on generaliza- tions from other fields of prevention in which they have been tested. This is notably the case with respect to research on issues of implementation and sustainability of programs. For example, the "community partnership" grants of OSAP require the applicants to have community coalitions. This require- ment is based on strictly anecdotal experience from drug abuse prevention projects, and a little research on coalitions in other fields. A second major concern is that the study of how comprehensive pro- grams that incorporate drug prevention are implemented; how training is carried out, with what effect on trainee attitudes, knowledge, and behavior; and how concepts and findings are diffused or disseminated. REFERENCES Abrams, D.B., J.P. Elder, R.A. Carleton, T.M. Lasater, and L.M. Artz 1986 Social learning principles for organizational health promotion: an integrated ap- proach. Pp. 28-51 in M.F. Cataldo and T.J. Coates, eds., Health and Industry: A Behavioral Medicine Perspective. New York: John Wiley. Allanson, J.F. 1978 School nursing services: some current justifications and cost-benefit implications. Journal of School Health 48:603-607. Allen, J., and R.F. Allen 1990 A sense of community, a shared vision and a positive culture: core enabling factors in successful culture-based change. Pp. 5-18 in R.D. Patton and W.B. Cissel, eds., Community Organization: Traditional Principles and Modern Appli- cations. Johnson City, Tenn.: Latchpins Press.
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