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Preventing Drug Abuse: What Do We Know? (1993)

Chapter: Appendix: Community Settings and Channels for Prevention

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Suggested Citation:"Appendix: Community Settings and Channels for Prevention." National Research Council. 1993. Preventing Drug Abuse: What Do We Know?. Washington, DC: The National Academies Press. doi: 10.17226/1883.
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Suggested Citation:"Appendix: Community Settings and Channels for Prevention." National Research Council. 1993. Preventing Drug Abuse: What Do We Know?. Washington, DC: The National Academies Press. doi: 10.17226/1883.
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Suggested Citation:"Appendix: Community Settings and Channels for Prevention." National Research Council. 1993. Preventing Drug Abuse: What Do We Know?. Washington, DC: The National Academies Press. doi: 10.17226/1883.
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Suggested Citation:"Appendix: Community Settings and Channels for Prevention." National Research Council. 1993. Preventing Drug Abuse: What Do We Know?. Washington, DC: The National Academies Press. doi: 10.17226/1883.
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Suggested Citation:"Appendix: Community Settings and Channels for Prevention." National Research Council. 1993. Preventing Drug Abuse: What Do We Know?. Washington, DC: The National Academies Press. doi: 10.17226/1883.
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Suggested Citation:"Appendix: Community Settings and Channels for Prevention." National Research Council. 1993. Preventing Drug Abuse: What Do We Know?. Washington, DC: The National Academies Press. doi: 10.17226/1883.
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Suggested Citation:"Appendix: Community Settings and Channels for Prevention." National Research Council. 1993. Preventing Drug Abuse: What Do We Know?. Washington, DC: The National Academies Press. doi: 10.17226/1883.
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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.

COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 143 American Council of Life Insurance 1985 Wellness at the School Worksite: A Manual. Washington, D.C.: Health Insurance Association of America. American Medical Association 1986 Alcohol advertising, counteradvertising, and depiction in the public media. Jour nal of the American Medical Association 256:1485-1488. Arkin, E.B. 1990 Opportunities for improving the nation's health through collaboration with the mass media. Public Health Reports 105 :219-223. Atkin, C. 1987 Alcoholic-beverage advertising: its content and impact. Advances in Substance Abuse 1 (Suppl.) :267-287. Atkin, C.K. 1990 Effects of televised alcohol messages on teenage drinking patterns. Journal of Adolescent Health Care 11 (1): 10-24. Bandura, A. 1986 Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs: Prentice Hall. Basch, C.E. 1984 Research on disseminating and implementing health education programs in schools. (Proceedings of the National Heart, Lung, Blood Institute Conference on School Health Research) Journal of School Health 54:57-66. Basch, C.E., J.D. Eveland, and B. Portnoy 1986 Diffusion systems for education and learning about health. Family and Commu- nity Health 9(2):1-26. Battista, R.N., and A.D. Mickalide 1990 Integration of preventive services into primary care: a conceptual framework for implementation. Pp. 467-473 in R.B. Goldbloom and R.S. Lawrence, eds., Pre- venting Disease: Beyond the Rhetoric. New York: Springer-Verlag. Becker, M.H., and J. Joseph 1988 AIDS and behavioral change to reduce risk: a review. American Journal of Public Health 78:394-410. Becker, S.L., J.A. Burke, R.A. Arbogast, M.J. Naughton, I. Bachman, and E. Spohn 1989 Community programs to enhance in-school anti-tobacco efforts. Preventive Medi cine 18:221 -228. Best, J.A. 1989 Intervention perspectives on school health promotion research. Health Education Quarterly 16:299-306. Blackburn, H. 1987 Research and demonstration projects in community cardiovascular disease preven- tion. Journal of Public Health Policy 4:398-421. Block, G., W. Rosenberger, and B. Patterson 1988 Calories, fat and cholesterol: intake patterns in the U.S. population by race, sex and age. American Journal of Public Health 7 8: 1 150. Boyd, G.M.? and E.D. Glover 1989 Smokeless tobacco use by youth in the U.S. Journal of School Health 59:189-194. Bracht, N., ed. 1990 Health Promotion at the Community Level. Newbury Park, Calif.: Sage. Bracht, N., and L. Kingsbury 1990 Community organization principles in health promotion: a five-stage model. Pp. 66-88 in N. Bracht, ea., Health Promotion at the Community Level. Newbury Park, Calif.: Sage.

44 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? Breckon, D.J., J.R. Harvey, and R.B. Lancaster 1989 Community Health Education: Settings, Roles, and Skills, 2nd ed. Rockville, Md.: Aspen. Brinkerhoff, R.O. 1987 Achieving Results from Training: How to Evaluate Human Resource Development to Strengthen Programs and Increase Impact. San Francisco: Jossey-Bass Pub- lishers. Brown, E.R. 1984 Community organization influence on local public health care policy: a general research model and comparative case study. Health Education Quarterly 10:205- 234. Brunk, S.E., and J. Goeppinger 1990 Process evaluation: assessing re-invention of community-based interventions. Evaluation and the Health Professions 13:186-203. Bureau of the Census 1989 StatisticalAbstractof the United States: 1990, 109th ed. Washington, D.C.: U.S. Government Printing Office. Carlaw, R.W., M. Mittlemark, N. Bracht, and R. Luepker 1984 Organization for a community cardiovascular health program: experiences from the Minnesota Heart Health Program. Health Education Quarterly 11 :243-252. Carnegie Council on Adolescent Development 1989 Turning Points: Preparing American Youth for the 21st Century. New York: Carnegie Corporation. Chamberlin, R.W., ed. 1988 Beyond Individual Risk Assessment: Community Wide Approaches to Promoting the Health and Development of Families and Children. Washington, D.C.: Na- tional Center for Education in Maternal and Child Care. Chandler, W.U. 1986 Worldwatch Paper 68: Banishing Tobacco. Washington, D.C.: Worldwatch Institution. Chavis, D.M., and A. Wandersman 1990 Sense of community in the urban environment: a catalyst for participation and community development. American Journal of Community Psychology 18:55-81. Chavis, D.M., J.H. Hogge, D.W. McMillan, and A. Wandersman 1986 Sense of community through Brunswik's lens: a first look. Journal of Community Psychology 14:24-40. Christenson, J.A., K. Fendley, and J.W. Robinson, Jr., eds. 1989 Community Development in Perspective. Ames: Iowa State University Press. Clark, N.M. 1987 Social learning theory in current health education practice. Pp. 251-275 in W.B. Ward, ea., Advances in Health Education and Promotion, Vol. 2. Greenwich, Conn.: JAI Press Inc. Coates, T., R. Stall, and C. Hoff 1988 Changes in High Risk Behavior Among Gay and Bisexual Men Since the Begin- ning of the AIDS Epidemic. Washington, D.C.: Office of Technology Assess- ment, U.S. Congress. Cohen, S., ed. 1979 New Directions in Patient Compliance. D.C. Heath. Collings, G.H., Jr. 1982 Perspectives of industry regarding health promotion. Pp. 119-126 in R.S. Parkinson and Associates, Managing Health Promotion in the Workplace: Guidelines for Implementation and Evaluation. Palo Alto, Calif.: Mayfield Publishing Co. Lexington, Mass.: Lexington Books,

COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 145 Connell, D.B., and R.R. Turner 1985 The impact of instructional experience and the effects of cumulative instruction. Journal of School Health 55 :324-331. Connell, D.B., R.R. Turner, and E.F. Mason 1985 Summary findings of the school health education evaluation: health promotion effectiveness, implementation and costs. Journal of School Health 55:316-32. Cook, R., and A. Harrell 1987 Drug abuse among working adults: prevalence rates and recommended strategies. Health Education Research 2:353-359. Cook, T.D., and H.J. Walberg 1985 Methodological and substantive significance. Journal of School Health 55:340- 343. Coombs, J.A., J.B. Silversin, E.M. Rogers, and M.E. Drolette 1981 The transfer of preventive health technologies to schools: a focus on implementa- tion. Social Science and Medicine 15A:789-799. Cornacchia, H.J., L.K. Olsen, and C.J. Nickerson 1988 Health in Elementary Schools, 7th ed. St. Louis, Mo. College Publishing. Courtwright, D., H. Joseph, and D. Des Jarlais Times Mirror/Mosby 1989 Addicts Who Survived: An Oral History of Narcotic Use in America, 1923-1965. Knoxville: University of Tennessee. Couto, R.A. 1990 Promoting health at the grass roots. Health Affairs 9(2):144-151. Creswell, W.H., and I.M. Newman 1989 School Health Practice, 9th ed. St.Louis, Mo.: Times MirrorlMosby. Cuca, R., and C.S. Pierce 1977 Experimentsin Family Planning: Lessonsfromthe Developing World. Baltimore, Md.: Johns Hopkins University Press. Davis, M.F., and D.C. Iverson 1984 An overview and analysis of the Health Style Campaign. Health Education Quar- terly 11:253-272. Dignan, M., and P. Ca~T 1986 Program Planning for Health Education and Health Promotion. Philadelphia, Pa.: Lea and Febiger. Donovan, J.E., and R. Jessor 1985 Structure of problem behavior in adolescence and young adulthood. Journal of Consulting and Clinical Psychology 53:890-904. Duhl, L. 1986 The healthy city: its function and its future Health Promotion 1:55-60. Dwore, R.B., and M.W. Kreuter 1980 Reinforcing the case for health promotion Family and Community Health 2:103- 119. Dwyer, T., J.P. Pierce, C.D. Hannam, and N. Burke 1986 Evaluation of the Sydney "Quit. For Life" anti-smoking campaign: part II: changes in smoking prevalence. Medical Journal of Australia 144:344-347. Easterby-Smith, M. 1986 Evaluation of Management Education, Training and Development. Brookfield, Vt.: Gower Publishing Co. Farquhar, J.W. 1978 The community-based model of life style intervention trials. American Journal of Epidemiology 108: 103-1 1 1.

146 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? Farquhar, J.W., S.P. Fortmann, P.D. Wood, and W.L. Haskell 1983 Community studies of cardiovascular disease prevention. Pp. 170-182 in N.M. Kaplan and J. Stamler, eds., Prevention of Coronary Heart Disease: Practical Management of Risk Factors. Philadelphia, Pa.: W.B. Saunders Co. Farquhar, J.W., S.P. Fortmann, J.A. Flora, C.B. Taylor, W.L. Haskell, P.T. Williams, N. Maccoby, and P.D. Wood 1990 Effects of community-wide education on cardiovascular disease risk factors the Stanford 5-city Project. Journal of the American Medical Association 264:359- 365. Feighery, E., and T. Rogers 1990 Building and maintaining effective coalitions. How-To Guides on Community Health Promotion. Palo Alto, Calif.: Health Promotion Resource Center, Stanford Center for Research on Disease Prevention. Fielding, J.E. 1982 Preventive medicine and the bottom line. Journal of Occupational Medicine 24:907- 916. Fielding, J.E., and L. Breslow 1983 Health promotion programs sponsored by California employers. American Jour- nal of Public Health 73 :538-542. Fiore, M.C., T.E. Novotny, J.P. Pierce, E.J. Hatziandreu, K.M. Patel, and R.M. Davis 1989 Trends in cigarette smoking in the United States: the changing influence of gen der and race. Journal of the American Medical Association 261:49-55. Fitz-enz, J. 1984 How to Measure Human Resources Management. New York: McGraw-Hill. Flay, B.R. 1986 Mass media linkages with school-based programs for drug abuse prevention. Journal of School Health 56:402-406. Flay, B.R. 1987a Social psychological approaches to smoking prevention: review and recommenda tions. Pp. 121-180 in Advances in Health Education and Promotion, Vol. 2. Greenwich, Conn.: JAI Press Inc. Flay, B.R. 1987b Selling the Smokeless Society: 56 Evaluated Mass Media Programs and Cam paigns Worldwide. Washington, D.C.: American Public Health Association. Food Marketing Institute 1989 Trends: Consumer Attitudes and the Supermarket. Washington, D.C.: Food Marketing Institute. Freudenberg, N. 1984 Not in Our Backyards! Community Action for Health. New York: Monthly Review Press. Gaziano, C. 1985 Neighborhood newspapers and neighborhood leaders: influences on agenda set- ting and definitions of issues. Communication Research 12:568-594. Glanz, K., F.~. Lewis, and B.K. Rimer, eds. 1990 Health Behavior and Health Education: Theory, Research, and Practice. San Francisco: Jossey-Bass. Glynn, T.J. 1981 Psychological sense of community: measurement and application. Human Rela tions 34:789-818. Glynn, T.J. 1989 Essential elements of school-based smoking prevention programs. Journal of School Health 59:181-188.

COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 147 Green, L.W. 1970a Should health education abandon attitude-change strategies? Perspectives from recent research. Health [Education Monographs 1(30):25-48. Green, L.W. 1970b Status Identity and Preventive Health Behavior. Berkeley, Calif.: Pacific Health Education Reports No. 1, University of California School of Public Health. Green, L.W. 1977 Evaluation and measurement: some dilemmas for health education. American Journal of Public Health 67:155-161. Green, L.W. 1986 The theory of participation: a qualitative analysis of its expression in national and international health policies. Pp. 211-236 in W. Ward, ea., Advances in Health Education and Health Promotion, Vol. 1. Greenwich, Conn.: JAI Press. Green, L.W. 1990 The revival of community and the public obligation of academic health centers. Pp. 148-164 in R. Bulger, R.E. Bulger, and S. Reiser, eds., The Role of the Aca- demic Health Center in Humanizing Medicine. Ames, Iowa: University of Iowa Press. Green, L.W., and A.L. McAlister 1984 Macro-intervention to support health behavior: some theoretical perspectives and practical reflections. Health Education Quarterly 11(3):323-339. Green, L.W., and M.W. Kreuter 1991 Health Promotion Planning: An Educational and Environmental Approach. Palo Alto, Calif.: Mayfield. Green, L.W., and J. Raeburn 1988 Health promotion: what is it? What will it become? Health Promotion Interna- tional 3:151-159. Green, L.W., P. Heit, D.C. Iverson, L.J. Kolbe, and M. Kreuter 1980 The School Health Curriculum Project: its theory, practice and measurement experience. Health Education Quarterly 7:14-34. Green, L.W., P.D. Mullen, and S. Maloney, eds. 1984 Large-scale health education campaigns. Health Education Quarterly 11: whole issue 3. Green, L.W., N.H. Gottlieb, and G. Parcel 1991 Diffusion theory extended and applied. In W. Ward and F.M. Lewis, eds., Ad- vances in Health Education and Promotion, Vol. 3. London: Jessica Kingsley Publishers. Greene, J.C., R. Louis, and S.J. Wycoff 1990 Preventive dentistry. II. Peridontal diseases, malocclusion, trauma, and oral can- cer. Journal of the American Medical Association 263:421-425. Gunn, W.J., D.C. Iverson, and M. Katz 1985 Design of the school health education evaluation. Journal of School Health 55:301- 304. Haynes, R.B., D.W. Taylor, and D.L. Sackett, eds. 1979 Compliance in Health Care. Baltimore, Md.: Johns Hopkins University Press. Hertel, V. 1982 Changing times in school nursing. Journal of School Health 52:313-314. Holder, H.D. 1991 Community Prevention Trialsfor Alcohol Problems: Methodological Issues. New York: Praeger.

148 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? Holder, H., and N. Giesbrecht 1989 Conceptual issues: perspectives on the community in action research. Pp. 27-40 in N. Giesbrecht, P. Conley, R. W. Denniston, L. Gliksman, H. Holder, A. Pederson, R. Room, and M. Shain, eds. Research, Action, and the Community: Experiences in the Prevention of Alcohol and Other Drug Problems. Office of Substance Abuse Prevention Monograph 4, DHHS Pub. No. (ADM) 89-1651. Rockville, Md: Office for Substance Abuse Prevention. Hunt, S. 1990 Building alliances: professional and political issues in community participation: examples from a community development project. Health Promotion Interven tions 5:179-185. Israel, B.A. 1985 Social networks and social support: implications for natural helper and commu- nity level interventions. Health Education Quarterly 12:65-80. Jernigan, D.H., and J.F. Mosher 1987 Preventing alcohol-related motor vehicle crashes: a policy agenda for the nation. Contemporary Drug Problems 14:243-278. Katzman, M.S., and K.J. Smith 1989 Evaluation of occupational health promotion programs. Employee Assistance Quarterly 4(3):27-46. King, J.A., L.L. Morris, and C.T. Fitz-Gibbon 1987 How to Assess Program Implementation. Newbury Park, Calif.: Sage Publica tions. Kolbe, L.J. 1982 What can we expect from school health education? Journal of School Health 52: 145-150. Kolbe, L.J., and D.C. Iverson 1980 Research in school health education: a needs assessment. Pp. 177-194 in Pro- ceedings of the Planning Meeting on Cancer Education. Bethesda, Md.: U.S. Department of Health, Education and Welfare. Kolbe, L.J., and D.C. Iverson 1983 Integrating school and community efforts to promote health: strategies, policies and methods. Hygie: International Journal of Health Education 3:40-47. Kolbe, L.J., L.W. Green, J. Foreyt, L. Darnell, K. Goodrick, H. Williams, D. Ward, A.S. Korton, I. Karacan, R. Widmeyer, and G. Stainbrook Appropriate functions of health education in schools: improving health and cogni- tive performance. Pp. 171-216 in N.A. Krasnegor, J.D. Arasteh, and M.F. Cataldo, eds., Child Health Behavior: A Behavioral Pediatrics Perspective. New York: Wiley. Kotler, P., and E.L. Roberto 1989 Social Marketing: Free Press. Kottke, T.E., P. Puska, I.T. Solomen, et al. 1986 Strategies for Changing Public Behavior. New York: The 1985 Projected effects of high-risk versus population-based prevention strategies in coronary heart disease. American Journal of Epidemiology 121:697-704. Kreuter, M.W., and P.A. Reagan 1980 Health education: coming of age in the schools. Pp. 75-95 in Proceedings of the Planning Meeting on Cancer Education. Bethesda, Md.: U.S. Department of Health and Human Services. Kreuter, M.W., G.M. Christenson, and A. Divencenzo 1982 The multiplier effect of the health education risk reduction grants program in 28 states and 1 territory. Public Health Reports 97:510-515.

COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 149 Lando, H.A., B. Loken, B. Howard-Pitney, and T. Pechacek 1990a Community impact of a localized smoking cessation contest. American Journal of Public Health 80:601-603. Lando, H.A., P.G. McGovern, F.X. Barrios, and B.D. Etringer l990b Comparative evaluation of American Cancer Society and American Lung Associa- tion smoking cessation clinics. American Journal of Public Health 80:554-559. Lasater, T., D. Abrams, L. Artz, P. Beaudin, L. Cabrera, J. Elder, A. Ferreira, P. Knisley, G. Peterson, A. Rodriques, P. Rosenberg, R. Snow, and R. Carleton 1984 Lay volunteer delivery of a community-based cardiovascular risk factor change program: the Pawtucket Experiment. Pp. 1166-1170 in J.D. Matarazzo, S.M. Weiss, J.A. Herd, N.E. Miller, and S.M. Weiss, eds., Behavioral Health: A Hand book of Health Enhancement and Disease Prevention. New York: John Wiley and Sons. Lawrence, R.S. 1990 The role of the physician in promoting health. Health Affairs 9:122-132. Levit, K.R., and C.A. Cowan ' 1991 Business, households, and governments: health care costs, 1990. Health Care Financing Report 13:83-93. Leviton, L.C., and R.O. Valdiser 1990 Evaluating AIDS prevention: outcome, implementation, and mediating variables. Evaluation and Program Planning 13 :55-66; Light, L., and I.R. Contento 1989 Changing the course: a school nutrition and cancer education curriculum devel- oped by the American Cancer Society and the National Cancer Institute. Journal of School Health 59:205-209. Maloney, S.K., and J.C. Hersey 1984 Getting messages on the air: findings from the 1982 alcohol abuse prevention campaign. Health Education Quarterly 1 1 :273 -292. Manoff, R.K. 1985 Social Marketing: New Imperative for Public Health. New York: Praeger. Marliland, R.E., and M.L. Vincent 1990 Improving resource allocation in a teenage sexual risk reduction program. Socio- Economic Planning Science 24:35-48. Matarazzo, J.D., S.M. Weiss, J.A. Herd, N.E. Miller, and S.M Weiss, eds. 1984 Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: Wiley. McCoy, H.V., S.E. Dodds, and C. Nolan 1990 AIDS intervention design for program evaluation: the Miami community outreach project. Journal of Drug Issues 20:223-243. McDonald, P., and R. Estep 1985 Prime time drug depictions. Contemporary Drug Problems 14:419-438. McGinnis, J.M., D. Shopland, and C. Brown 1987 Tobacco and health: trends in smoking and smokeless tobacco consumption in the United States. Annual Peview of Public Health 8:441-467. McMillan, D W., and D.M. Chavis 1986 Sense of community: a definition and theory. Journal of Community Psychology 14:6-23. Mechanic, D.M., ed 1983 Handbook of Health, Health Care, and the Health Professions. New York: The Free Press. Metropolitan Life Foundation 1988 An EvaIuation of Comprehensive Health Education in Amer~can Public Schools.

150 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? Louis Harris and Associates, conducted for the Metropolitan Life Foundation, New York. Study no. 874024. Millar, W.J., and B.E. Naegele 1987 Time to Quit program. Canadian Journal of Public Health 78:109-111. Minkler, M. 1989 Health education, health promotion and the open society: an historical perspec- tive. Health Education Quarterly 16:17-30. Minkler, M. 1990 Improving health through community organization. Pp. 257-287 in K. Glanz, F.M. Lewis, and B.K. Rimer, eds., Health Behavior and Health Education. San Fran- cisco: Jossey-Bass. Mullen, P.D., and J.G. Zapka 1982 Guidelines for Health Promotion and Education Services in HMOs. Washington, D.C.: U.S. Government Printing Office. Nader, P.R., J.G. Sallis, T.L. Patterson, I.S. Abramson, J.W. Rupp, K.L. Senn, C.J. Atkins, B.E. Roppe, J.A. Morris, J.P. Wallace, and W.A. Vega 1989 A family approach to cardiovascular risk reduction: results from the San Diego Family Health Project. Health Education Quarterly 16:229-244. National Research Council 1989 Improving Risk Communication. Washington, D.C.: National Academy Press. National Research Council 1993 Under the Influence: Drugs and the American Worker. Committee on Drug Use in the Workplace, Commission on Behavioral and Social Sciences and Education. Washington, D.C.: National Academy Press (in press). National Restaurant Association 1989 Foodservice Industry Forecast. Washington, D.C.: Malcolm M. Knapp Research. Newman, I.M. 1980 Smoking cessation from an educational perspective. Pp. 97-126 in Proceedings of the Planning Meeting on Cancer Education. Bethesda, Md.: U.S. Department of Health, Education and Welfare. Nutbeam, D., and J. Catford 1987 The Welsh Heart Programme evaluation strategy: progress, plans and possibili- ties. Health Promotion 2:5-18. Oberschall, A. 1973 Social Conflict and Social Movements. Englewood Cliffs, N.J.: Prentice-Hall. Office of Disease Prevention and Health Promotion 1990 Public health communication. In U.S. Department of Health and Human Services, Prevention '891'90: Federal Programs and Progress. Washington D.C.: U.S. Government Printing Office. Olsen, L.K., R. Hambleton, R. Simon, D.B. Connell, R.R. Turner, D. Orenstein 1985 Development and application of the student test used in the school health educa- tion evaluation. Journal of School Health 55:309-315. Orlandi, M.A. 1986 The diffusion and adoption of worksite health promotion innovations: an analysis of barriers. Preventive Med. icin e 1 5 :5 2 2-5 3 6. Orlandi, M.A., C. Landers, R. Weston, and N. Haley 1990 Adoption and diffusion of health promotion innovations. Pp. 288-313 in K. Glanz, F.M. Lewis, and B.K. Rimer, eds., Health Behavior and Health Education: Theory, Research and Practice. San Francisco, Calif.: Jossey-Bass. O'Rourke, T.W., and D.B. Stone 1980 School health education: cancer prevention and control. Pp. 143-175 in Proceed

COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 151 ings of the Planning Meeting on Cancer Education. Bethesda, Md.: U.S. Depart- ment of Health, Education and Welfare. Ostrow, D.G. 1985 AIDS prevention through effective education. Daedalus: Journal of the American Academy of Arts and Sciences 118:229-254. Ottoson, J.M., and L.W. Green 1987 Reconciling concept and context: a theory of implementation. Advances in Health Education and Promotion 2:339-368. Owen, S.L., M.A. Kirkpatrick, S.W. Lavery, H.L. Gonser, S.R. Nelson, R.L. Davis, E.F. Mason, and D.B. Connell 1985 Selecting and recruiting health programs for the school health education evalua- tion. Journal of School Health 55 :305-308. Paehlke, R.C. 1989 Environmentalism and the Future of Progressive Politics. New Haven, Conn.: Yale University Press. Parcel, G.S., and T. Baranowski 1981 Social learning theory and health education. Health Education 12(3):14-18. Parcel, G.S., M.P. Eriksen, C.Y. Lovato, N.H. Gottlieb, S.G. Brink, and L.W. Green 1989a The diffusion of school-based tobacco-use prevention programs: project descrip- tion and baseline data. Health Education Research 4(1):111-124. Parcel, G.S., W.C. Taylor, S.G. Brink, N. Gottlieb, K. Engquist, N.M. O'Hara, and M.P. Eriksen 1989b Translating theory into practice: intervention strategies for the diffusion of a health promotion innovation. Family and Community Health 12(3): 1 - 13. Parkinson, R.S., and Associates, eds. 1982 Managing Health Promotion in the Workplace: Guidelines for Implementation and Evaluation. Palo Alto, Calif.: Mayfield. Patton, C. 1985 Sex and Germs: The Politics of AIDS. Boston, Mass.: South End Press. Pentz, M.A. 1986 Community organization and school liaisons: how to get programs started. Jour- nal of School Health 56:382-388. Pentz, M.A., C. Cormack, B. Flay, W.B. Hansen, C.A. Johnson 1986 Balancing program and research integrity in community drug abuse prevention: Project STAR approach. Journal of School Health 56:389-393. Pentz, M.A., J.H. Dwyer, D.P. MacKinnon~ B.R. Flay, W.B. Hansen, E.Y.I. Wang, and C.A. Johnson 1989 A multicommunity trial for primary prevention of adolescent drug abuse: effects on drug use prevalence. Journal of the American Medical Association 261:3259- 3266. Perry, C.L., ed. 1986 Special issue on community programs for drug abuse prevention. lournal of School Health 56(9):357-418. Perry? C.L., R.V. Luepker, D.M. Murray, C. Kurth, R. Mullis, S. Crockett, and D.R. Jacobs, Jr. 1988 Parent involvement with children's health promotion: the Minnesota Home Team. American Journal of Public Health 78:1156-1160. Pertschuk, M., and A. Erikson 1987 Smoke Fighting: A Smoking Control Movement Building Guide. New York: American Cancer Society. Pertschuk, M., and W. Schaetzel 1989 The People Rising: The Campaign Against the Bork Nomination. New York: Thunder's Mouth Press.

52 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? Phillips, J.J. 1983 Handbook of Training Evaluation and Measurement Methods. Houston, Texas: Gulf Publishing Co. Pierce, J.P., M.C. Fiore, T.E. Novotny, E.J. Hatziandreu, and R.M. Davis 1989 Trends in cigarette smoking in the United States: educational differences are increasing. Journal of the American Medical Association 261:56-60. P. Macaskill, and D. Hill Long-term effectiveness of mass media led antismoking campaigns in Australia. American Journal of Public Health 80:565-569. , and K. Middleton Elementary School Health Instruction, 2nd ed. St. Louis, Mo.: Times Mirror/ Mosby College Publishing. P. Haines, K. Reidy Food consumption trends of U.S. women: patterns and determinants between 1977 and 1985. American Journal of Clinical Nutrition 49:1307-1319. , D.M. Anderson, and M.P. Eriksen 1989 Application of diffusion theory to health promotion research. Family and Commu nity Health 12(3):73-81 . Protess, D.L., D.R. Leff, S. Brooks, and M.T. Gordon 1985 Uncovering rape: the watchdog press and the limits of agenda setting. Public Opinion Quarterly 49:19-37. Puska, P., A. McAlister, J. Pekkola, and K. Koskela 1981 Television in health promotion: evaluation of a national programme in Finland. International Journal of Health Education 24:2-14. Puska, P., A. Nissinen, I. Tuomilehto, J.T. Salonen, K. Koskela, A. McAlister, T.E. Kottke, N. Maccoby, and J.W. Farquhar 1985 The community-based strategy to prevent coronary heart disease: conclusions from the ten years of the North Karelia Project. Annual Review of Public Health 6: 147-193. Reid, W.J., and P. Hanrahan 1988 Measuring implementation of social treatment. In K.J. Conrad and C. Roberts- Gray, eds., Evaluating Program Environments. San Francisco, Calif.: Jossey- Bass. Resnick, L.B. 1987 Educat~on and Learning to Think. Washington, D.C.: National Academy Press. Riger, S., and P.J. Lavraka 1981 Community ties: patterns of attachment and social interaction in urban neighbor- hoods. American Journal of Community Psychology 9:55-66. Pierce, J.P., 1990 Pollock, M. 1989 Popkin, B., 1 989 Portnoy, B. Rimer, B.K. 1990 Perspectives on intrapersonal theories in health education and health behavior. Pp. 140-157 in K. Glanz, F.M. Lewis, and B.K. Rimer, eds., Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, Calif.: Jossey Bass. Room, R. 1989 Introduction community action and alcohol problems: the demonstration project as an unstable mixture. Pp. 1-25 in Giesbrecht, P. Conley, R.W. Denniston, et al., eds., Research, Action, and the Community: Experiences in the Prevention of Alcohol and Other Drug Problems. Office of Substance Abuse Prevention Mono graph 4, DHHS Publ. No (ADM) 89-1651. Rockville, Md.: Office for Substance Abuse Prevention.

COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION 153 Rothman, J., and E.R. Brown 1989 Indicators of societal action to promote social health. Pp. 202-220 in S.B. Kar, ea., Health Promotion Indicators and Actions. New York: Springer Publishing Co. Samuels, S.E. 1990 Project LEAN: a national campaign to reduce dietary fat consumption. American Journal of Health Promotion 4:435-40. Scheirer, M.A. 1990 The life cycle of an innovation: adoption versus discontinuation of the fluoride mouth rinse program in schools. Journal of Health and Social Behavior 31:203- 215. Schiller, P., A. Steckler, L. Dawson? and F. Patton 1987 Participatory Planning in Community Health Education: A Guide Based on the McDowell County, West Virginia, Experience. Oakland, Calif.: Third Party Asso- ciates. Schorr, L.B. 1989 Within Our Reach: Breaking the Cycle of Disadvantage. New York: Anchor Books, Doubleday. Shaw, D.L., and M.E. McCombs 1989 Dealing with illicit drugs: the power- and limits of mass media agenda setting. Pp. 113-120 in P.J. Shoemaker, ea., Communication Campaigns About Drugs: Government, Media, and the Public. Hillsdale, N.J.: Lawrence Erlbaum Associ- ates. Shoemaker, P.J., ed. 1989 Communication Campaigns About Drugs: Government, Media, and the Public. Hillsdale, N.J.: Lawrence Erlbaum Associates. Simons-Morton, D.G., B.G. Simons-Morton, G.S. Parcel, and J.G. Bunker 1988 Influencing personal and environmental conditions for community health: a multi- level intervention model. Family and Community Health 1 1:25-35. Solomon, M.Z., and W. DeJong 1986 Recent sexually transmitted disease prevention efforts and their implications for AIDS health education. Health Education Quarterly 13:301-316. Spretnak, C., and F. Capra 1984 Green Politics. New York: E.P. Dutton, Inc. Staropoli, C.J., and C.F. Waltz 1978 Developing and Evaluating Educational Programs for Heatth Care Providers. Philadelphia: F.A. Davis Co. Stone, E.J., C.L. Perry, and R.V. Luepker 1989 Synthesis of cardiovascular behavioral research for youth health promotion. Health Education Quarterly 16(2):155-169. Terre, L., R.S. Drabman, and E.F. Meydrech 1990 Relationships among children's health-related behaviors: a multivariate, develop- mental perspective. Preventive Medicine 19:134-146. Thompson, B., and S. Kinne 1990 Social change theory: applications to community health. Pp. 45-65 in N. Bracht, ea., Health Promotion at the Community Level. Newbury Park, Calif.: Sage. U.S. Preventive Services Task Force 1989 Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 I,z~erventions. Baltimore, Md.: Williams & Wilkins. Vartiainen, E., P. Puska, K. Tossavainen, L. Viri, E. Niskanen, S. Moisio, A. McAlister, and U. Pallonen 1986 Prevention of non-communicable diseases: risk factors in youth, the North Karelia Youth Project (1984-1988). Health Promotion 1:269-283.

154 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? Wallack, L. 1984 Drinking and driving: toward a broader understanding of the role of mass media. Journal of Public Health Policy 5 :471-496. Wallack, L. 1990 Media advocacy: promoting health through mass communication. Chap. 16 in K. Glanz, F.M. Lewis, and B.K. Rimer, eds., Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, Calif.: Jossey-Bass. Wallack, L., and C.K. Atkin, eds. 1990 Mass Media and Health. Newbury Park, Calif.: Sage Publications. Wallack, L., W. Breed, and J. Cruz 1987 Alcohol on prime-time television. Journal of Studies on Alcohol 48:33-38. Warner, K.E., and H.A. Murt 1983 Premature deaths avoided by the antismoking campaign. American Journal of Public Health 73:672-677. Williams, L.S. 1986 AIDS risk reduction: a community health education intervention for minority high risk group members. Health Education Quarterly 13:407-422. Williams, R.M. 1990 Rx: social reconnaissance. Foundation News 31(4):24-29. Winett, R.A., D.G. Altman, and A.C. King 1990 Conceptual and strategic foundations for effective media campaigns for preventing the spread of HIV infection. Evaluation and Program Planning 13:91-104. Young, J. 1981 The amplification of drug use. In S. Cohen and J. Young, eds., The Manufacture of News. London: Constable.

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As the nation's drug crisis has deepened, public and private agencies have invested huge sums of money in prevention efforts. Are the resulting programs effective? What do we need to know to make them more effective? This book provides a comprehensive overview on what we know about drug abuse prevention and its effectiveness, including

  • Results of a wide range of antidrug efforts.
  • The role and effectiveness of mass media in preventing drug use.
  • A profile of the drug problem, including a look at drug use by different population groups.
  • A review of three major schools of prevention theory--risk factor reduction, developmental change, and social influence.
  • An examination of promising prevention techniques from other areas of health and human services.

This volume offers provocative findings on the connection between low self-esteem and drug use, the role of schools, the reality of changing drug use in the population, and more.

Preventing Drug Abuse will be indispensable to anyone involved in the search for solutions, including policymakers, antidrug program developers and administrators, and researchers.

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