# Presentation: 009421

## 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 environments in which *all* children encounter threats to their health—including illicit drugs, alcohol, and tobacco

## Strategies Targeting Individualized Environments

*Socialize, Instruct, Guide, Counsel*

**Family**

**School**

**Health Care  Providers**

**INDIVIDUAL YOUTH**

**Faith Community**

**Strategies Targeting the Shared Environment**
*Support, Thwart*

**Availability**

**Regulations**

**Norms**

**ALL YOUTH**

## 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, and 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., HMO’s, 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 ID’s 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

## Concordant Evolution

**Norms**

**Time 1**

**Availability**

**Regulations**

**Concordant Evolution**
**Change of degree rather than type**
**Incremental**

**Time 2**

**Availability**

**Regulations**

**NEW****Norms**

**NEW****Norms**

**Time 3**

**CHANGED****Availability**

**NEW ****Regulations**

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

- No single 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

## Disconcordant Evolution

**Norms**

**Time 1**

**Availability**

**Regulations**

**Disconcordant Evolution**
**Change of type rather than degree**
**Major/Precipitous**

**Time 2**

**Availability**

**Norms**

**NEW ****Regulation**

**UNCHANGED**** ****Norms**

**Time 3**

**PREVIOUS****Regulations**

**UNCHANGED****Availability**

## 1964 Surgeon General’s Report

**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

**1964 Surgeon General’s Report**

**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!!

## 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

**1950–1965**

## 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?

**1970–1985**

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

## 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

**1998**

*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*

## Alcohol

**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 are committed to trying the program/strategy/policy

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

***Factors***

- Needs of the target are well understood
- Perspectives of the target are acknowledged and respected
- People like the 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
- The program/strategy/ policy is  endorsed by people like them
- Targets believe that disseminators understand their needs (disciplinary/sectorial cultural competence)
- Targets have the opportunity to participate in the development or refinement of the strategy

- The program/strategy/ policy is:
- Compatible with local circumstance
- Not overly complex
- An opportunity for local reinvention/refinement
- An 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
- Ongoing support and boosters

## Phase

***Phase***

**Pre-Dissemination**

***Goals***

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

***Factors***

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

## Dissemination

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

***Phase***

**Dissemination**

***Goals***

***Factors***

## Conversion

- a good idea
- superior to current practice

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

***Phase***

**Conversion**

***Goals***

***Factors***

## Adoption

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

***Phase***

**Adoption**

***Goals***

***Factors***

## Implementation

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

***Phase***

**Implementation**

***Goals***

***Factors***

## Myth 

**Myth **

**Reality**

- Environmental prevention strategies let individual users off the hook by locating the cause of AOD problems in  “the system.”

- Environmental strategies seek to make healthy choices easier, but individuals are responsible for their own behavior.
- Violator of minimum purchase age can be fined or prosecuted.
- Violator of community norms may be socially sanctioned or ostracized.

- Environmental strategies are really efforts to coerce good behavior through social engineering by well-meaning bureaucrats.

- Environmental strategies are one of a number of social policy tools for shaping behavior deemed beneficial to the body politic.
- Other such strategies include provisions of the tax code, the penal code, and road signs.
- All these strategies are under the ultimate control of the citizens who elect public officials (and throw them out of office).

- The free market in a democratic society operates according to a social compact.
- Citizens support a positive business climate (through tax policies, import/export policies, protection from infringement, infrastructure development, etc.).
- In return, they expect businesses and corporations to be good citizens (not knowingly do harm, market unsafe products, price gouge, etc.).

- Advocates of environmental prevention strategies are anti-business—they want to interfere with free enterprise and limit the free speech rights of corporations.

- Advocates of environmental prevention strategies:
- Hug all manner of things.
- Are of many minds concerning the snail darter and Mao
- Eat junk food.

- Advocates of environmental prevention strategies are closet tree-huggers, mung bean eaters, snail darter lovers, and Mao quoters.