What Works, Best PracticesByKarol L. Kumpfer, Ph.D.DirectorCenter for Substance Abuse Prevention

Extent of the Drug Problem:

Tobacco, alcohol, and drug abuse is a serious health and social problem worldwide.

Drug abuse has been increasing in the USA in adolescents since 1992. Last year drug abuse increased 27% in 12-17 year olds.

Tobacco, alcohol, and drug abuse significantly contributes to rising health care costs and societal problems.

Substance Abuse Prevention:What Works!

Good News: We know how to prevent drug abuse by strengthening families, schools, and communities.

Bad News: Prevention of drug abuse is not easy. There are no quick fixes. A media campaign is not enough.

SUPPLY REDUCTION INTERDICTION CROP ERADICATION POLICY AND LAWS REDUCE ACCESS INCREASE COST SYSTEM CHANGE FAMILY SCHOOL COMMUNITYINDIVIDUAL CHANGE PROGRAMS KNOWLEDGE ATTITUDE/NORMS SKILLSAGENT/DRUGENVIRONMENTHOST/PERSONPublic Health Model Triangle

The Intervention Spectrum for Behavioral DisordersCaseIdentificationStandardTreatmentfor KnownDisordersCompliancewith Long-TermTreatment(Goal: Reduction inRelapse and Recurrence)Aftercare(IncludingRehabilitation)PreventionTreatmentMaintenanceSource: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.IndicatedDiagnosed YouthSelectiveHealth RiskGroupsUniversalGeneral Population

Prevention: Three types of prevention interventions (Mrazek & Haggerty, IOM, 1994).1. Universal (primary prevention with general population)

2. Selective (secondary prevention with high-risk groups, such as children of alcoholics, inner city youth, pregnant unmarried girls, etc.)

3. Indicated (secondary prevention with identified problem youth already manifesting a risk factor, i.e., school dropouts, delinquent youth, youth already smoking or drinking, etc.)

U.S. Drug Abuse Prevention Workshop ObjectivesSession III: Substance Abuse Prevention: What Works!

Purpose: To give participants an understanding of effective substance abuse prevention strategies

The Need for Community Coalitions

Community coalitions have become very popular for health promotion and disease prevention. The U.S. Center for Substance Abuse Prevention has initiated more than 250 community partnerships nationwide. Additional AOD community coalitions have been implemented by: 1. State and local governments 2. The Henry J. Kaiser Family Foundation

The Need for Community Coalitions (cont.)

3. The Robert Wood Johnson Foundations Fighting Back coalitions4. The National Cancer Institute's COMMIT and ASSIST tobacco and cancer reduction programs5. The U.S. Centers for Disease Control and Preventions Planned Approach to Community Health (PATCH) health promotion program

A Rigorous National Evaluation

Age Groups Surveyed in the 24 Partnerships and 24 Comparison Communities

Adults are Less Likely to Use Illicit Drugs When:Living in partnership communities,Participating in drug prevention activities,Living in neighborhoods safe from drugs, andDisapproving of drug use.

Outcome Evaluation Results:Characteristics of Successful Partnerships

30 Day Illicit Drug UseMALES

30 Day Alcohol UseMALES

Four Steps for Choosing a Research-based Prevention Program

Step 1: Read Reviews of the Research Literature

Psychology Bulletin article (Hawkins, Catalano, & Miller (1992), Communities That Care (Hawkins, et al., 1993), The Making of a Drug-Free America (Falco, 1993). Drug Abuse Prevention in Multi-ethnic Youth (Botvin, Schinke, and Orlandi, 1995).

Four Steps for Choosing a Research-based Prevention Program (Continued)

Step 2: Gather Local Data

Step 3: Determine Why These High-Risk Individuals Use Drugs

Step 4: Select the Best Prevention Intervention

Step 4.1: Where in the Prevention Continuum to Intervene? First you should decide where in the Prevention Possibilities Frontier or risk continuum you want to intervene:

1. Before there are any risk indicators with general population using universal approaches,

2. Using selective approaches for high-risk groups, or

3. Using indicated approaches for individuals already using or manifesting symptoms of use (dropping grades, isolation, and antisocial behavior).

Step 4.2: Which Sites to Focus UponSchool, Family, Community?

Step 4.3: Choosing the Most Effective Approach

Peer-focused Prevention Approaches

Final pathway to Drug Use= Peer Norms and Pressure

Effective Approaches

1. Peer Resistance Training2. Normative Education.

Resistance to peer pressure can be increased through involvement in peer resistance training programs which have been shown to delay initiation of drug use (Dielman, Shope, Leech, & Butchart, 1989; Pentz, et al., 1989).

Prevention Matrix

The following table provides an overview of Universal, Selective, and Indicated as defined by school-based approaches, family focused approaches, and community based approaches.

Prevention Matrix (Continued)

Strengthening Schools, Families and Communities Approaches

1.Information Prevention Approaches

Programs employing this strategy provide awareness and knowledge of:

Pharmacological effects of drugs Health, psychological and social consequences of abuse School and community attitudes, norms, legal sanctions, and sanctions General health education.

1.Information Prevention Approaches. (Continued)

Results

1.Increase students' knowledge about drugs 2.Impact on decreasing or delaying use is not known because most information programs do not measure behavioral objectives (Moskowitz, 1983)

Information-only approaches to prevention have been criticized on the following grounds:

1. Knowledge Alone May Not Change Behavior 2. Youth most at-risk for drug use are school drop-outs 3. The information source often not considered credible by youth 4. Most educational programs too short to produce behavior changes 5. Often drug information is not specifically designed to match the appropriate local cultural and ethnic traditions

Information about consequences may deter low-risk youth from drug initiation, particularly with highly addictive drugs or drugs with well accepted negative effects (e.g., designer drugs)

Information is helpful to those living with drug users or to those wanting to know how to identify symptoms of drug use, intervention methods, and referral sources

Strengthening Schools, Families and Communities Approaches(Continued)

2. Prevention Education and Skills Training Programs

More intensive (more hours per person) than information dissemination programs

Cost more per participant

2. Prevention Education and Skills Training Programs (Continued) Examples

Life skills training Peer and media resistance training Classroom or small group sessions Peer leader/helper programs Children of substance abuse groups Parenting and family skills training classes Youth or adult involvement in design and implementation helps (National Assembly, 1994)

The skills training or social competency approaches behaviorally train students to resist pressures to use drugs and to learn social skills through three different strategies:

1) The Social Influences Approach involving media persuasion resistance training and peer resistance social skills training, used in Project STAR, and I-STAR in the Midwestern Prevention Project (Pentz 1983; Pentz, et al., 1989) and the DARE program

2. The Normative Education Approach which encourages adoption of norms against drug use and corrects inflated estimates found in youth about the number of youth who actually use drugs (Hansen, 1992; Hansen & Graham, 1991)

3. The Life Skills or Social Skills Approach (Botvin and associates., 1990 (a,b,c)) teach youth how to communicate, control stress and feelings of anger or anxiety, restore self-concept, choose prosocial friends, increase social status, and resist media and peer pressure to use drugs

Intervention methods

1.Demonstrations of effective and ineffective behaviors 2.Trainer demonstrations 3.Participant role plays with feedback4. Reinforcement for changed behavior 5.Role Modeling6. Positive peer group norms

Results

Modest reductions in onset and prevalence of cigarette smoking, alcohol, and marijuana use if:

Interactive classes better than lectures Peer led classes better than teacher-led classes Some negative effects in students who were already using

Strengthening Schools, Families and Communities Approaches(Continued)

2. Alternative Programs Including recreational, sports, cultural, and educational activities

Used with high-risk individuals because of the increased cost The theoretical justification is that providing individuals with "alternative highs incompatible with substance use will reduce use.

2. Alternative Programs (Continued) Also, some research supports a link between sensation or thrill seeking personality and drug use

Types

Experiential Education Programs involving wilderness experiences, ropes courses, mountain climbing, rapelling, and rafting.

Community Service Programs (removing graffiti or developing community murals), building homes, and volunteering to help others (Tobler, 1986)

2. Alternative Programs (Continued)

Examples

1. Amazing Alternatives was developed by Murray and Perry (1985).2. CSAP High-risk Youth Grants with experiential education programs

Results

Effectiveness Unclear (Schaps and associates (1981)

Results (Continued)

Some alternative activities (academic, religious, and active hobbies) decrease use and others (entertainment, sports, social, extracurricular, and vocational activities) promote increased use

Critical ingredient is who youth associate with in the activities

Strengthening Schools, Families and Communities Approaches(Continued)

4. Intervention Approaches

Indicated prevention programs for drug users or individuals showing mental health symptoms of risk (e.g., delinquency, aggression, depression, and other anti-social behavior)

Strategies involve problem identification, screening and referrals to special therapeutic programs

4. Intervention Approaches (Continued)

Examples:

Student assistance programs (Morehouse, 1979) Peer counseling programs Parent-peer groups for troubled youth Teen hot lines and crisis intervention (Tobler, 1986, 1992)

Community Based PreventionInterventions

1. Public Awareness and Media Campaigns

Results

Media campaigns do affect the community's social norms when combined with other community prevention strategies (Wallach, 1985) In addition, the public demand for credible information about drugs is increasing and should be satisfied by accurate and scientifically credible messages

1. Public Awareness and Media Campaigns. (Continued)

Examples

The Partnership for A Drug-free America (1994) reports producing more than 400 anti-drug ads for their national campaign worth $1.8 billion in media donations. They were recently awarded advertising's most prestigious award for effectiveness the Grand Effie

2. Youth Development Services.

Implemented in community agencies serving high-risk youth with the purpose of generally improving youth development and outcomes. Many of these selective or indicated prevention programs are funded with CSAP or local county or state funds from State Block Grant or state legislative appropriations.

Community Based PreventionInterventions (Continued)

3. Social Interaction Skills Training Approaches:

The Botvins Life Skills Training Program: a drug prevention curriculum implemented in Philadelphia alternative Scholls was found to increase knowledge about tobacco and alcohol use, negative attitudes toward marijuana use, and decrease school problems, incidents of drunker aggression, and legal problems.Community Based PreventionInterventions (Continued)

3. Social Interaction Skills Training Approaches: (Continued)

The Smart Moves Program: a drug prevention curriculum based on the original pear resistance skills training program was implemented in public housing projects by Boys and Girls Clubs. Studies showed that the presence of crack was lower in developments served by Clubs with Smart Moves (Schinke, Orlandi, and Cole 1992

4. Mentoring Programs:

Convey positive values, attitudes and life skills through a one-to-one relationship with a positive role model, who may be a culturally matched community volunteer, college student, parent, or business professional, or retired person. Becoming very popular, currently this approach is not as frequently used (found in 14% of the first 75 CSAP high-risk youth grants), except as part of a more comprehensive programCommunity Based PreventionInterventions (Continued)

5. Tutoring Programs:

Tutoring programs reduce academic problems by improving academic achievement. Tutors can be mentors, college students, grandparents, professionals, or teachers to tutor students in school or after school.

Community Based PreventionInterventions (Continued)

6. Rites of Passage Programs:

These programs focus on:

1. Responsibility training, skills training, resiliency, community bonding, and spiritual values

Community Based PreventionInterventions (Continued)

6. Rites of Passage Programs (Continued)

Example:

The Comprehensive Afro-American Adolescent Services Project operated by the University of Cincinnati included twenty 2-hour rites of passage discussion groups with community action projects and entrepreneurial training

Critical Role of FamiliesThe family is the social unit primarily responsible for child rearing functions.When families fail to fulfill this responsibility, the entire society suffers.Families are responsible for providing:Physical necessitiesEmotional supportLearning opportunitiesMoral guidanceBuilding self-esteem and resilience

CSAP Family PEPS (1998)Effective Family Intervention Strategies 1. Parent training 2.Family skills training 3.Family in-home support 4.Family therapy

Principles of EffectiveFamily-Focused Programs1.There Is No One Best Family-Focused Program. Select Programs Based On: Ages of Children Cultural Appropriateness General Level of Family Needs (Universal Low Risk Families)

Specific Family Needs. Different Types of Family Interventions Are Used to Modify Different Risk and Protective Factors.

Strengthening Americas FamiliesProgram Matrix

Thirty-four Effective family intervention programs can be found on web site

www-medlib.med.utah.edu/healthed/ojjdp.htm

or call (801) 581-7718 at the University of Utah Health Education Department

Slide 9

Aside from this general profile of all the partnerships as just shown on the last few slides, the cross-site evaluation collected an intensive amount of data from 24 representative partnerships and 24 matched comparison communities. The data were based on surveys of representative samples of adults, 10th graders, and 8th graders, at two points in time, in the 48 communities. All told, about 31,000 eighth graders, 26,000 tenth graders, and 27,000 adults were surveyed (different and adults were surveyed at two points in time). Due to administrative clearance delays, the first set of data was not collected until 1994-1995. Therefore, we do not have the ideal baseline for this evaluation period.The data also included four annual site visits to the 24 partnerships.I am now going to turn this over to Dr. Yin, who will tell you about the individual behavior outcomes that came out of the evaluation.

A(TitlesandGridauto)B(Dataonclick)C clickABCSlide 12 Statistical path analysis of the survey data showed that, by the second point in time, there were statistically significant relationships among the following five conditions:being in a partnership community (not a comparison community) being involved in prevention activitiesbeing in a neighborhood perceived to be safe from drugshaving a disapproving attitude toward drug use andbeing less likely to use illicit drugs. In other words, adults who lived in a partnership community, participated in drug prevention activities, lived in neighborhoods they perceived to be safe from drugs, and disapproved of drug use, were found to be less likely to use illicit drugs. So these findings begin to provide support for the community partnership strategy in relation to behavioral outcomes, not just organizational outcomes.

Slide 13 The paired analysis also was a way of beginning to identify successful partnerships. Of the eight partnerships that exhibited statistically significant reductions, compared to their matched comparison communities, shown on the map on the previous slide, five also demonstrated those characteristics that previous literature claimed were important in being associated with successful partnerships. We therefore considered these five partnerships to be models of successful partnerships, because they had shown statistically significant outcomes and emulated the desirable processes.Eight characteristics were important and may be considered as goals in operating your current coalitions: a widely shared vision embraced by nearly everyone in the communitya comprehensive vision covering all segments of the communityan inclusive and broad-based membershipa strong core of committed partnersextensive prevention activities and support for local prevention policiesdecentralized units, with task forces or mini-partnerships covering smaller areas within the partnership areaavoidance or resolution of severe internal conflictreasonable staff turnover