Module IX: CommunityBased Substance Abuse Prevention

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Module IX Community-Based Substance Abuse
Prevention
Project MAINSTREAM
November 2005
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Learning Objectives

• Health Care Professionals will be able 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 be able 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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The Mental Health Intervention Spectrum
Treatment
Standard Treatment for Known
Disorders
Case Identification
Maintenance
Prevention
Indicated
Compliance with Long-term Treatment
(Goal Reduction in Relapse and Recurrence)
Selective
After-care (Including Rehabilitation)
Universal
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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 perspectivefocus on individual factors
  and lifestyle issues
• Public health perspectivefocus on law, policies
  and practices that affect production, marketing
• CombinedProject 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.
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.
3. Design, conduct, and analyze pilot studies
and confirmatory and replication trials of the
preventive program.
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PRECEDE - PROCEED Model

• Phase 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 Platform

• The 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 settingsfor example,
  schools, clubs, faith-based organizations, and
  the mediaare 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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Risk 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)
Personal/Individual

• Other predispositions
• Impulsivity
• Hostility
• Rebelliousness
• Deficits in social skills
• Early aggression
• Alienation

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Risk Factors (continued)

• Personal/Individual
• Problem Behaviors
• Juvenile delinquency
• Violence
• Teen pregnancy
• Dropping out of school

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Protective Factors

• Personal/Individual
• 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

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Protective Factors (continued)

• Personal/Individual
• 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)

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Risk Factors

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

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Risk Factors (continued)

• Family
• Parental use of alcohol and drugs
• Parental positive attitudes toward substance use

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Protective Factors

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

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Risk Factors

• School
• Substandard academic environment
• A negative, disorderly, and unsafe school climate
• Low teacher expectations of student achievement

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Protective Factors

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

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Risk Factors

• Peer Group
• Negative influence of peers
• Involvement with friends who use alcohol and
  drugs
• Involvement with peers who engage in other risky
  behaviors

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Protective Factors

• Peer Group
• Positive peer group activities
• Positive peer group norms
• Peer groups with skills to resist negative
  influences
• Peer groups with good decision-making skills

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Risk Factors

• Community
• Community norms that promote or permit substance
  use
• Poverty
• Community disorganization
• Cultural disenfranchisement

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Risk Factors (continued)

• Community
• Customs/policies that encourage substance use
• Pro-use messages in the general media.
• Pro-use targeted promotion
• High availability of substances

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Protective Factors

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

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Risk Factors

• Societal
• Availability of substances
• National conditions
• Poor economy and unemployment
• Discrimination and marginalization
• Media messages

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Protective Factors

• Societal
• Teaching children about media messages
• Counter-advertising messages
• Decreasing substance availability/accessibility

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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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Designing Effective Prevention Programs

• Promote protective factors
• Reduce risk factors
• Consider theories of behavioral change
• Include strategies that enhance client-provider
  interaction and participation
• Consider cultural factors

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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
(continued)

• 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 prevention
• Complex, multifaceted process
• Domain of health care professionals