Module IX:

Community-Based Substance Abuse Prevention

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Learning ObjectivesHealth Care Professionals will have the

opportunity to: Define community-based prevention. Discuss types and levels of prevention. Compare frameworks for preventive

interventions. Identify risk and protective factors

associated with substance use disorders. Cite theories of behavioral change. Discuss cultural influences on prevention.

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Learning Objectives (continued)

Health Care Professionals will have the opportunity to:

Define the role of the health careprofessional in prevention.

Discuss general and specific strategiesfor community-based prevention.

Identify evaluation aims for community-based prevention programs.

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Introduction

Substance use disorders take greater toll than any other preventable health problem.

Substance use disorders occur across the lifespan.

Communities are appropriate sites for preventive interventions.

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Definition of Prevention

Prevention is a proactive process that empowers individuals and systems to meet the challenge of life events and transitions by creating and reinforcing conditions that promote healthy behaviors and lifestyles.

(CSAP, 1994)

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Prevention Activities Classified

Approach (demand vs. supply reduction)

Levels of prevention• Universal• Selective• Indicated

Focus (direct vs indirect)

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Mental Health Approach to Prevention

Universal Preventive Intervention• Desirable for everyone in eligible population.

Selective Preventive Intervention• Targeted for individuals or subgroups at

significantly higher risk than average.

Indicated Preventive Intervention• Targeted for high-risk individuals with

minimal but detectable signs/symptoms.

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Universal

Selective

Indicated

After-care(Including Rehabilitation)

Compliance withLong-term Treatment(Goal: Reduction inRelapse and Recurrence)

Standard Treatment forKnown Disorders

CaseIdentification

Prevention Maintenance

Treatment

The Mental Health Intervention Spectrum

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Examples of Research-Based Drug Prevention Programs

Life Skills Training (Botvin, et al., 1990)

Project STAR (Pentz, et al., 1989)

Strengthening Families Program (Kumpfer, et al., 1994)

Reconnecting Youth Program (Eggert, et al., 1994)

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Approaches to Community-Based Prevention

Clinical perspective—focus on individual factors and lifestyle issues

Public health perspective—focus on law, policies and practices that affect production, marketing

Combined—Project Northland

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Frameworks for Community-Based Prevention

Preventive Intervention Research Cycle

PRECEDE - PROCEED

SAMHSA Prevention Platform

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Prevention Intervention Research Cycle

1. Identify problem or disorder(s) and review information to determine its extent.

2 With an emphasis on risk and protective factors, review relevant information - both from fields outside prevention and from existing intervention research programs.

3. Design, conduct, and analyze pilot studies and confirmatory and replication trials of the preventive program.

4. Design, conduct, and analyze large-scale trials of the preventive intervention program.

5. Facilitate large-scale implementation and ongoing evaluation of the preventive intervention program in the community.

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PRECEDE - PROCEED ModelPhase 1: Social assessment: Consideration of quality of

life by determining subjectively defined problems of individuals and communities.

Phase 2: Epidemiological assessment: Identification of specific health goals or problems that may contribute to social goals (disability, discomfort, fertility, fitness, morbidity, mortality, physiological risk factors).

Phase 3: Behavioral and environmental assessment: Identification of behavioral factors (compliance, consumption patterns, coping, preventive actions, self care, utilization) and environmental factors (economic, physical, services, social).

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PRECEDE -PROCEED Model (continued)

Phase 4: Educational and organizational assessment: Identification of predisposing factors (knowledge, attitudes, beliefs, values, perceptions), reinforcing factors, attitudes and behavior of health and personnel, peers, parents, employers, and enabling factors (availability of resources, accessibility, referrals, rules, laws, skills).

Phase 5: Administrative and policy assessment: Assessment of organizational and administrative capabilities and resources, for development and implementation of a program.

Phase 6,7,8,9: Implementation and process, impact and outcome evaluation.

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SAMHSA Prevention PlatformThe SAMHSA Prevention Platform is an online resource designed to assist professionals and community volunteers to engage in substance abuse prevention. The framework includes the following areas:

• Assessment – determining your prevention needs.• Capacity – improving your capabilities.• Planning – developing a strategic plan.• Implementation – putting your plan into action.• Evaluation – documenting the outcomes of your work.

Http://preventionplatform.samhsa.gov

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Model

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Lessons from Prevention Research

Sixteen Evidence-Based Principles

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Principle 1

Prevention programs should enhance protective factors and reverse or reduce risk factors

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Principle 2

Prevention programs should address all forms of substance abuse alone or in combination

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Principle 3

Prevention programs should address the type of drug abuse problem in the local community, target modifiable risk factors, and strengthen identified protective factors

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Principle 4

Prevention programs should be tailored to address risks specific to population or audience characteristics

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Principle 5

Family-based prevention programs should enhance family bonding and relationships and include parenting skills; practice in developing, discussing, and enforcing family policies on substance abuse; and training in drug education and information

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Principle 6

Prevention programs can be designed to intervene as early as preschool to address risk factors for drug abuse, such as aggressive behavior, poor social skills, and academic difficulties

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Principle 7

Prevention programs for elementary school children should target improving academic and social-emotional learning to address risk factors for drug abuse, such as early aggression, academic failure, and school dropout. Education should focus on the following skills

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Principle 7 (continued)

self-control; emotional awareness; communication; social problem-solving; and academic support, especially in reading

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Principle 8

Prevention programs for middle or junior high and high school students should increase academic and social competence with the following skills

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Principle 8 (continued)

study habits and academic support; communication; peer relationships; self-efficacy and assertiveness; drug resistance skills; reinforcement of anti-drug attitudes; and strengthening of personal commitments against

drug abuse.

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Principle 9

Prevention programs aimed at general populations at key transition points, such as the transition to middle school, can produce beneficial effects even among high-risk families and children. Such interventions do not single out risk populations and, therefore, reduce labeling and promote bonding to school and community

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Principle 10

Community prevention programs that combine two or more effective programs, such as family-based and school-based programs, can be more effective than a single program alone

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Principle 11

Community prevention programs reaching populations in multiple settings—for example, schools, clubs, faith-based organizations, and the media—are most effective when they present consistent, community-wide messages in each setting

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Principle 12

When communities adapt programs to match their needs, community norms, or differing cultural requirements, they should retain core elements of the original research-based intervention

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Principle 13

Prevention programs should be long-term with repeated interventions (i.e., booster programs) to reinforce the original prevention goals. Research shows that the benefits from middle school prevention programs diminish without follow-up programs in high school

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Principle 14

Prevention programs should include teacher training on good classroom management practices, such as rewarding appropriate student behavior. Such techniques help to foster students’ positive behavior, achievement, academic motivation, and school bonding

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Principle 15

Prevention programs are most effective when they employ interactive techniques, such as peer discussion groups and parent role-playing, that allow for active involvement in learning about drug abuse and reinforcing skills

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Principle 16

Research-based prevention programs can be cost-effective. Similar to earlier research, recent research shows that for each dollar invested in prevention, a savings of up to $10 in treatment for alcohol or other substance abuse can be seen

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Risk and Protection Factors

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Risks Factors Indicators for potential problem

occurrence or vulnerability

Characteristics that occur more often for those who develop substance use problems

(NCADI, 1990)

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Protective Factors

Presence of positive influences

Not merely absence or opposite of risk factors

(NCADI, 1990)

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Resilience

An ability to recover from or adjust easily to misfortune or change (Webster)

Successful adaptation despite risk and adversity (Wolin and Wolin, 1995)

Protective factors lead to resilience

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Six Life Areas Individual Family environment Peer association School/work-related Community environment Society-related

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Risk Factors

Genetic/biomedical factors Attitudes and predispositions Perception of risk

Personal/Individual

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Risk Factors (continued)

Other predispositions• Impulsivity• Hostility • Rebelliousness

Deficits in social skills• Early aggression • Alienation

Personal/Individual

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Risk Factors (continued)

Problem Behaviors: • Juvenile delinquency

• Violence

• Teen pregnancy

• Dropping out of school

Personal/Individual

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Protective Factors

Good social skills Caring and cooperative Positive sense of self Problem-solving skills Sense of humor Autonomy and purpose Genetics/biomedical factors Pro-social bonding

Personal/Individual

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Protective Factors (continued)

Genetically controlled variation of aldehyde hydrogenase (ALDH2), called ALDH2-2, in 10% of Asians creates intense reaction to alcohol.

Lower alcoholism risk is also associated with genetically controlled variants of alcohol dehydrogenase (ADH2, ADH3) in Asians and several other ethnic groups

(Schuckit, 1999)

Personal/Individual

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Risk Factors

Abusive or conflict-ridden families Economic deprivation Reduced supervision Limited formal controls Limited social supports Poor family discipline, and problem-

solving

Family

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Risk Factors (continued)

Parental use of alcohol and drugs Parental positive attitudes toward

substance use

Family

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Protective Factors

Positive bonding Lack of severe criticism Basic trust High parental expectations Clear rules Parental involvement in activities Involvement in religious institutions

Family

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Risk Factors

Substandard academic environment A negative, disorderly, and unsafe

school climate Low teacher expectations of

student achievement

School

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Protective Factors

Caring and support High expectations Clear standards and rules Youth participation in tasks and

decisions

School

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Risk Factors

Negative influence of peers Involvement with friends who use

alcohol and drugs Involvement with peers who engage

in other risky behaviors

Peer Group

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Protective Factors

Positive peer group activities Positive peer group norms Peer groups with skills to resist negative

influences Peer groups with good decision-making

skills

Peer Group

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Risk Factors

Community norms that promote or permit substance use

Poverty Community disorganization Cultural disenfranchisement

Community

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Risk Factors (continued)

Customs/policies that encourage substance use

Pro-use messages in the general media.

Pro-use targeted promotion High availability of substances

Community

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Protective Factors

Caring and support High expectations Opportunities for participation Presence of effective prevention programs Laws/norms that discourage substance use

Community

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Risk Factors

Availability of substances National conditions

• Poor economy and unemployment• Discrimination and marginalization

Media messages

Societal

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Protective Factors

Teaching children about media messages

Counter-advertising messages Decreasing substance

availability/accessibility

Societal

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Risk Factors for the Elderly

Polypharmacy Increased biologic sensitivity to

substances Negative coping responses Change in role status Change in health status Loss

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Risk Factors for the Elderly (continued)

Loneliness Boredom Lack of social support Depression

(Marcus, 1993, Schonfeld & Dupree, 1991; Fingerhood, 2000)

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Protective Factors for the Elderly Positive coping responses to life

changes Supportive family Supportive social networks Aware of drug interactions and potential

for biologic sensitivity to substances(Welte & Mirand, 1995; Simoneau & Bergeron, 2000)

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Role of the Health Care Practitioner

In the clinical area: To identify people who have risk factors; To build protective factors by giving

healthy prevention messages; To set up the office space to promote

health and prevent substance use problems.

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Role of the Health Care Practitioner (continued)

In the community: To participate in community and school

activities; To utilize home visits; To work in professional organizations to

promote prevention activities; To advocate with government officials on all

levels to change laws/policies; To promote Healthy People 2010 objectives.

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Promote protective factors Reduce risk factors Consider theories of behavioral change Include strategies that enhance client-

provider interaction and participation Consider cultural factors

Designing Effective Prevention Programs

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Theories of Change

Social cognitive theory (Bandura, 1986)

Problem-based theory (Jessor & Jessor, 1997)

Peer cluster theory (Oetting & Beauvois, 1986)

Theory of ethnic identity (Phinney, 1990)

Transtheoretical model (Prochaska & DiClemente. 1983)

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Cultural Competence Link between cultural competence and

success or failure of preventive interventions

Successful programs take into account dominant and non-dominant cultures n which individuals live

Growing body of literature to guide the practitioner/researcher in developing cultural competence programs

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General Prevention Strategies

Information dissemination Development of life-coping skills Provision of alternatives Community development Advocacy for a healthy

environment Problem identification

(CSAP, 1999)

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Elements of Effective Programs

Standardized training materials Social learning theory methods Periodic booster sessions Techniques to extend program

beyond the setting. (Pentz, 1999)

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Combined Strategies in Communities are Most Effective

Curriculum in schools Parent involvement Support by community leaders and health

professionals Enforcement of policies Use of mass media to enforce messages

(Pentz, 1999)

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Settings for Community-Based Strategies Schools Religious organizations Community centers Youth organizations Family centers Senior centers Libraries and other community facilities

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Community-Based Participatory Approaches

Participatory Action research Community-based participatory research Action research

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Community-Based Participatory Approaches

Assure that programs are tailored to community

Increase community capacity to deliver interventions

Result in increased knowledge and social change

Involve interactions between researcher and stakeholders

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Evaluation Rationale A systematic way to monitor clients’ outcomes

that result from intervention. Feedback that reflects the need to make

adjustments. Evidence that the program works and is cost

effective. Findings that contribute to the development of

“best practices” in prevention efforts. A method to disseminate findings to others in

the field. (Prevention Programs for Youth, 1998)

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Evaluation Process

• Documenting all aspects of implementation of the program

Outcomes• Short-term benefits: new knowledge,

improved skills and changed attitudes• Long-term benefits: changed behaviors,

reduced risks and enhanced protective factors.

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The Getting to Outcomes Framework

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Summary

Community-based substance abuse preventionComplex, multifaceted processDomain of health care

professionals