# Presentation: 062954

## Integrating Environmental Change Theory Into Prevention Practice

**Integrating Environmental Change Theory Into Prevention Practice**

- Michael Klitzner, Ph.D.

## Prevention Strategies Attempt To Alter Two Kinds of Environments:

- Individualized Environments
- the environments in which *individual* children grow, learn, and mature
- Shared Environments
- the environment in which *all* children encounter threats to their health–including illicit drugs, alcohol, and tobacco

## Slide 3

## Factors in the Shared Environment

*Norms*
*Availability*
*Regulations*

## Norms

- Basic* *orientations concerning the “rightness or wrongness,” acceptability or unacceptability, and/or deviance of specific behaviors for a specific group of individuals
- E.g.,
- it is *wrong* for *anyone* to use illicit drugs
- it is *okay* for *adults* to drink in moderation
- The basis for a variety of* specific attitudes* that support or undermine the particular prevention strategies we may wish to implement

## Availability

- The inverse of the sum of resources (time, energy, money) that must be expended to obtain a commodity (alcohol, marijuana, cigarettes)
- The more resources required to get something, the lower the availability

## Regulations

- Formalized laws, rules, policies that serve to control availability and codify norms and that specify sanctions for violations
- May be instituted by governments, public agencies (e.g., police departments, school systems), or private organizations (e.g., HMOs, hospitality establishments, convenience stores)

## The Probability of an Undesirable Behavior Is Decreased to the Extent That:

- There exist regulations that discourage the behavior
- Community norms disapprove of the behavior
- The commodities needed to engage in the behavior are not easily available

## A Basic Premise:

*Strategies that address both individualized environments and the shared environment are important components of a comprehensive approach to prevention*

## An Important However:

- The Secretary’s Initiative will focus largely on the shared environment for three reasons:
*Efficiency*
*Celerity*
*Enhancement*

## Efficiency

- Strategies directed at the shared environment are efficient because they affect every member of a target population
- E.g.,
- Removing dealers from street corners and training convenience store clerks to check IDs reduces the availability of illicit drugs and tobacco for all neighborhood youth

## Celerity

- Strategies aimed at the shared environment often produce more rapid results than do strategies aimed at individual environments
- E.g.,
- Enforcement of the minimum alcohol purchase age or increases in alcohol prices (manipulations of availability) can produce more or less immediate reductions in youth alcohol use
- Pre-school programs to increase academic readiness and pro-social orientation may take many years to show results

## Two Caveats on Celerity

- Increased celerity may come at the cost of increased implementation complexity
- Beware the man or woman with the magic bullet (including yours truly)

## Enhancement

- Many communities currently have little in the way of a coordinated approach to the shared environment to complement their individualized environmental strategies

## Norms, Regulations, and Availability Play Leap-Frog

- Norms, regulations, and availability are interdependent and mutually supportive–they constitute stable systems that are tightly interwoven
- A change in any one of these factors will cause changes in the other two
- As norms (or availability or regulations) change, they tend to pull the other factors along with them

## Slide 16

## But Norms, Regulations, and Availability Play Leap-Frog Conservatively

- No one factor can change too much or too quickly
- Moderating pressure from the other two factors will tend to attenuate too rapid or too drastic a change in norms, regulations, or availability

## Slide 18

## Slide 19

## 1950–1965

**Norms**
*Smoking Is Unremarkable*
- You can smoke anywhere
*Cigarettes Are Good*
- I’m giving Luckies to all my friends this Xmas
*No Need To Worry*
- Not a cough in a carload

**Availability**
*Cigarettes Are Everywhere*
- Look in the crystal box on the coffee table
*Cigarettes Are Cheap*
- Can I borrow a quarter for a pack of Camels?

**Regulations**
*Smokey the Bear*
- Don’t throw a lighted cigarette from your car in a dry forest

## 1970–1985

**Norms**
*Smoking Is Sort of Dirty*
- Ask before you light up
*Cigarettes Are a Crutch*
- I’ve tried quitting a hundred times
*Smoking Is Dangerous to Smokers*
- Well, if he wants to kill himself . . .

**Availability**
*Cigarettes Are Not on Display*
- Whatever happened to our silver table lighter?
*Cigarettes Are Not Offered*
- Should a gentleman offer a lady a Lucky? No!

**Regulations**
*No-Smoking Areas*
- Smoking or non-smoking?

*Fines for Smoking*
- You will be subject to a fine of $25

## 1998

**Norms**
*Smoking Is a Form of Insanity*
- You SMOKE?????
*Cigarettes Are a Weapon of Mass Destruction*
- Smoking is the single greatest threat to the health of our Nation
*Smoking Is Dangerous to Everyone*
- Everyone knows that secondhand smoke causes . . .

**Availability**
*Cigarettes Are Expensive*
*Smokers Are Hidden*
- Isn’t that Dr. Horowitz smoking behind the dumpster?

**Regulations**
*No-Smoking Areas, Period*
- Welcome to Our Town—A smoke-free city

*Suits Against Tobacco Companies ***but . . .**
*No-Smoking Bars????*
- NO WAY!!

## Developing Prevention Strategies for the Shared Environment

- Two Principles
- the strongest prevention approaches will derive from considering norms, regulations, and availability as a package
- a strategy aimed at any one of these components should be viewed as an entry point into a systems consideration of all three

## Table 1

**Strategy**

**Primary Focus**

**Associated Norms**

**Associated Regulations**

**Associated Availability Issues**

**Needed Resources**

- Concerned Parent Groups/Safe Homes Coalitions

- Reinforce *norm* that parents can and should monitor children’s partying

- Underage youth should not have alcohol at parties
- Adults should not serve alcohol to underage youth in their homes

- Police policy to investigate youth gatherings where underage alcohol use is suspected
- Social host liability

- Pressure from parents on community alcohol outlets to check IDs

- Highly motivated parent volunteers to organize and sustain effort

- Citizen Surveillance

- Reduce *availability* of illicit drugs by making neighborhood riskier for dealers

- Community members are responsible for community well-being
- Illicit drugs are destructive to individual and community

- Police policy to respond expeditiously to calls from community members

- Dealers must keep moving around— possibly to less convenient locations. It is more difficult or expensive to sell.

- Highly motivated volunteers to organize and sustain effort
- Communications and surveillance equipment

## Approaches

*Science-Based Approaches*
*Logic-Based Approaches*
*Symbolic Approaches*

## Science-Based

**Science-Based**

**Logic-Based**

**Alcohol**

**Illicit Drugs**

**Tobacco**

- Enforcing minimum purchase age laws
- Controlling outlet densities
- Raising prices
- Server training
- School alcohol policies

- Keg registration
- Safe Homes coalitions
- Access control at community events
- Parent and community groups
- Police enforcement policies (e.g., warn and release)

- Citizen surveillance
- Nuisance abatement
- Needle exchange
- Crackdowns on dealers
- School drug policies

- Aggressive treatment of addicts
- Safe Homes coalitions
- Parent and community groups

- Enforcing minimum purchase age laws
- Raising prices
- Training merchants
- Establishing school tobacco policies

- Cessation programs
- Safe Homes coalitions
- Police enforcement policies (e.g., warn and release)

## A Practical Look at Dissemination Issues

***Phase***

- Pre-Dissemination

- Dissemination

- Conversion

- Adoption

- Implementation

***Goals***

- Products are designed to meet dissemination goals.
- Targets are clearly defined

- Targets are aware of the program/strategy/
- policy

- Targets believe the program/strategy/policy is:
- a good idea
- superior to current practice

- Targets committed to trying program/strategy/policy

- Targets successfully implement the program/strategy/
- policy goals

***Factors***

- Needs of target are well understood
- Perspectives of target are acknowledged and respected
- People like target are featured
- Language is appropriate

- Signal that stands out in surrounding “noise”
- Multiple channels
- Person-to-person contact

- Targets see concrete evidence of results
- Program/strategy/ policy endorsed by people like them
- Targets believe that disseminators understand their needs (disciplinary/sectorial cultural competence)
- Targets have opportunity to participate in development or refinement of strategy

- Program/strategy/ policy is:
- Compatible with local circumstance
- Not overly complex
- Opportunity for local reinvention/refinement
- Opportunity to deal directly with affective issues
- “Risk loves company”
- Technical assistance
- Necessary resources
- Market incentives

- Organizational support
- Adequate resources
- Necessary organizational restructuring
- System-level analysis of impacts
- On-going support and boosters

## Pre-Dissemination

***Phase***

***Goals***

- Products are designed to meet dissemination goals.
- Targets are clearly defined

***Factors***

- Needs of target are well-understood
- Perspectives of target are acknowledged and respected
- People like target are featured
- Language is appropriate

## Dissemination

- Signal that stands out in surrounding “noise”
- Multiple channels
- Person-to-person contact

***Phase***

***Goals***

***Factors***

## Conversion

- a good idea
- superior to current practice

- Targets see concrete evidence of results
- Program/strategy/policy endorsed by people like them
- Targets believe that disseminators understand their needs (disciplinary/sectorial cultural competence)
- Targets have opportunity to participate in development or refinement of strategy

***Phase***

***Goals***

***Factors***

## Adoption

- Program/strategy/policy is:
- Compatible with local circumstance
- Not overly complex
- Opportunity for local reinvention/refinement
- Opportunity to deal directly with affective issues
- “Risk loves company”
- Technical assistance
- Necessary resources
- Market incentives

***Phase***

***Goals***

***Factors***

## Implementation

- Organizational support
- Adequate resources
- Necessary organizational restructuring
- System-level analysis of impacts
- On-going support and boosters

***Phase***

***Goals***

***Factors***

## Slide 33