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OCR for page 119
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
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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
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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).
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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
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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,
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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.
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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
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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
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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
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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
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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.
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44
PREVENTING DRUG ABUSE: WHAT DO WE KNOW?
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Representative terms from entire chapter:
abuse prevention
