# Presentation: 382945

## “What Works, Best Practices”

- By
- Karol L. Kumpfer, Ph.D.
- Director
- Center for Substance Abuse Prevention

## Slide 2

## Extent of the Drug Problem:

• Tobacco, alcohol, and drug abuse is a serious                             
   health and social problem worldwide.

•  Drug abuse has been increasing in the USA in   
   adolescents since 1992.  Last year drug abuse 
   increased 27% in 12-17 year olds.

• Tobacco, alcohol, and drug abuse significantly  
   contributes to rising health care costs and 
   societal problems.

- • Tobacco, alcohol, and drug abuse is a serious
-    health and social problem worldwide.
- •  Drug abuse has been increasing in the USA in
-    adolescents since 1992.  Last year drug abuse
-    increased 27% in 12-17 year olds.
- • Tobacco, alcohol, and drug abuse significantly
-    contributes to rising health care costs and
-    societal problems.

- Substance Abuse Prevention:
- What Works!

## Good News:

   •  We know how to prevent drug abuse by   
      strengthening families, schools, and 
      communities.

Bad News:

   •  Prevention of drug abuse is not easy.  
      There are no quick fixes.  A media campaign is 
      not enough.

**  **
**   •**  We know how to prevent drug abuse by
-       strengthening families, schools, and
-       communities.
**Bad News:**
-    •  Prevention of drug abuse is not easy.
-       There are no quick fixes.  A media campaign is
-       not enough.

**   **• INTERDICTION
-    • CROP ERADICATION
-    • POLICY AND LAWS
-    • REDUCE ACCESS
-    • INCREASE COST

**   **• SYSTEM CHANGE
-    • FAMILY
-    • SCHOOL
-    • COMMUNITY

**INDIVIDUAL CHANGE PROGRAMS**
**   **• KNOWLEDGE
-    • ATTITUDE/NORMS
-    • SKILLS

**AGENT/DRUG**

**ENVIRONMENT**

**HOST/PERSON**

- Public Health Model Triangle

## The Intervention Spectrum  for Behavioral Disorders

- The Intervention Spectrum  for Behavioral Disorders

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- Source:  Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: * National Academy Press*, 1994.

**Indicated—**
**Diagnosed **
**Youth**

**Selective—**
**Health Risk**
**Groups**

**Universal—**
**General Population**

## Prevention:  Three types of prevention   

- interventions (Mrazek & Haggerty, IOM, 1994).

- 1. Universal (primary prevention with
-     general population)
- 2. Selective (secondary prevention
-     with high-risk groups, such as children
-     of alcoholics, inner city youth, pregnant
-     unmarried girls, etc.)
- 3. Indicated (secondary prevention with
-     identified problem youth already
-     manifesting a risk factor, i.e., school
-     dropouts, delinquent youth, youth
-     already smoking or drinking, etc.)

## U.S. Drug Abuse Prevention Workshop Objectives

**Session III:**Substance Abuse Prevention:  What Works!
**Purpose: **
- To give participants an understanding of effective substance abuse prevention strategies

## The Need for Community Coalitions

- 	• Community coalitions have become very popular 		for health promotion and disease prevention.
- 	• The U.S. Center for Substance Abuse Prevention 		has initiated more than 250 community 			partnerships nationwide.
- 	• Additional AOD community coalitions have been 		implemented by:
-     		1. State and local governments
-     		2. The Henry J. Kaiser Family Foundation

## The Need for Community Coalitions (cont.)

- 3. The Robert Wood Johnson Foundation’s “Fighting Back” coalitions
- 4. The National Cancer Institute's COMMIT and ASSIST tobacco and cancer reduction programs
- 5. The U.S. Centers for Disease Control and Prevention’s Planned Approach to Community Health (PATCH) health promotion program

## A Rigorous National Evaluation

- A Rigorous National Evaluation

***Age Groups Surveyed in the 24 Partnerships ***
***and 24 Comparison Communities***

**Notes:**
	Slide 9

 Aside from this general profile of all the partnerships 	as just shown on the last few slides, the cross-site 	evaluation collected an intensive amount of data 	from 24 representative partnerships and 24 		matched comparison communities.
 The data were based on surveys of representative 	samples of adults, 10th graders, and 8th graders, at 	two points in time, in the 48 communities.
 All told, about 31,000 eighth graders, 26,000 tenth 	graders, and 27,000 adults were surveyed (different 	and adults were surveyed at two points in time). 
Due to administrative clearance delays, the first set of 	data was not collected until 1994-1995.  Therefore, 	we do not have the ideal “baseline” for this 		evaluation period.
The data also included four annual site visits to the 24 	partnerships.
I am now going to turn this over to Dr. Yin, who will tell 	you about the individual behavior outcomes that 	came out of the evaluation.

## Adults are Less Likely to Use Illicit Drugs When:

- Living in partnership communities,
- Participating in drug prevention activities,
- Living in neighborhoods safe from drugs, and
- Disapproving of drug use.

**Notes:**
Slide 12

 Statistical path analysis of the survey data showed 	that, by the second point in time, there were 		statistically significant relationships among the 	following five conditions:
being in a partnership community (not a comparison 	community) 
being involved in prevention activities
being in a neighborhood perceived to be safe from drugs
having a disapproving attitude toward drug use and
being less likely to use illicit drugs.
 In other words, adults who lived in a partnership 	community, participated in drug prevention 		activities, lived in neighborhoods they perceived to 	be safe from drugs, and disapproved of drug use, 	were found to be less likely to use illicit drugs.
 So these findings begin to provide support for the 	community partnership strategy in relation to 	behavioral outcomes, not just organizational 		outcomes.

## Outcome Evaluation Results:Characteristics of Successful Partnerships

- Outcome Evaluation Results:Characteristics of Successful Partnerships

**Notes:**
Slide 13

 The paired analysis also was a way of beginning to identify 	“successful” partnerships.  Of the eight partnerships that 	exhibited statistically significant reductions, compared to 	their matched comparison communities, shown on the map 	on the previous slide, five also demonstrated those 		characteristics that previous literature claimed were 		important in being associated with successful partnerships.  	We therefore considered these five partnerships to be 	models of successful partnerships, because they had 		shown statistically significant outcomes and emulated the 	desirable processes.
Eight characteristics were important and may be considered as 	goals in operating your current coalitions:  
a widely shared vision embraced by nearly 		everyone in the community
a comprehensive vision covering all segments of the 	community
an inclusive and broad-based membership
a strong core of committed partners
extensive prevention activities and support for local 	prevention policies
decentralized units, with task forces or mini-		partnerships covering smaller areas within the 		partnership area
avoidance or resolution of severe internal 		conflict
reasonable staff turnover

## 30 Day Illicit Drug UseMALES

- 30 Day Illicit Drug UseMALES

## 30 Day Alcohol UseMALES

- 30 Day Alcohol UseMALES

## Four Steps for Choosing a 

- Research-based Prevention
- Program

- Step 1:  Read Reviews of the Research Literature
-     •  Psychology Bulletin article (Hawkins, Catalano,
-        & Miller (1992),
-     •  Communities That Care (Hawkins, et al., 1993),
-     •  The Making of a Drug-Free America
-        (Falco, 1993).
-     •  Drug Abuse Prevention in Multi-ethnic Youth
-        (Botvin, Schinke, and Orlandi, 1995).

## Four Steps for Choosing a 

- Research-based Prevention
- Program (Continued)

- Step 2:  Gather Local Data
- Step 3:  Determine Why These High-Risk
- 	   Individuals Use Drugs
- Step 4:  Select the Best Prevention Intervention

## Step 4.1:  Where in the Prevention Continuum 

**	****      ****to Intervene?**
-            First you should decide _where_ in the Prevention
-            Possibilities Frontier or risk continuum you want
-            to intervene:
-     1. Before there are any risk indicators with
-         general population using _universal_ approaches,
-     2. Using _selective_ approaches for high-risk groups, or
-     3. Using _indicated_ approaches for individuals already
-         using or manifesting symptoms of use (dropping
-         grades, isolation, and antisocial behavior).

## Step 4.2:  Which Sites to Focus Upon—School,

**	****      ****Family, Community?**
**Step 4.3:  Choosing the Most Effective Approach**

## Peer-focused Prevention 

- Approaches

- Final pathway to Drug Use= Peer Norms and Pressure
**Effective Approaches**
- 1. Peer Resistance Training
- 	2. Normative Education.
- Resistance to peer pressure can be increased
- through involvement in peer resistance training
- programs which have been shown to delay initiation
- of drug use (Dielman, Shope, Leech, & Butchart,
- 1989; Pentz, et al., 1989).

## Prevention Matrix

- The following table provides an overview of
*Universal*, *Selective*, and *Indicated* as defined by
- school-based approaches, family focused approaches,
- and community based approaches.

## Prevention Matrix (Continued)

## Strengthening Schools, Families and Communities Approaches 

- 1.**Information Prevention Approaches**
- 	Programs employing this strategy provide awareness and knowledge of:
- 	 • Pharmacological effects of drugs
- 	 • Health, psychological and social
-       consequences of abuse
- 	 • School and community attitudes, norms,
-       legal sanctions, and sanctions
-  	 • General health education.

## 1.Information Prevention Approaches.   (Continued)  

-        1.	Increase students' knowledge about drugs
-        2.	Impact on decreasing or delaying use is
-            not known because most information
-            programs do not measure behavioral
-            objectives (Moskowitz, 1983)

- 1.**Information Prevention Approaches**.   (Continued)

## • Information-only approaches to prevention have
  been criticized on the following grounds:  

	1. Knowledge Alone May Not Change Behavior  
    2. Youth most at-risk for drug use are school   
        drop-outs
    3. The information source often not considered 
        credible by youth
    4. Most educational programs too short to produce 
        behavior changes
    5. Often drug information is not specifically 
       designed to match the appropriate local cultural  
       and ethnic traditions 

-   been criticized on the following grounds:
- 	1. Knowledge Alone May Not Change Behavior
-     2. Youth most at-risk for drug use are school
-         drop-outs
-     3. The information source often not considered
-         credible by youth
-     4. Most educational programs too short to produce
-         behavior changes
-     5. Often drug information is not specifically
-        designed to match the appropriate local cultural
-        and ethnic traditions

## • Information about consequences may deter 

-    low-risk youth from drug initiation, particularly
-    with highly addictive drugs or drugs with well
-    accepted negative effects (e.g., designer drugs)
- 	• Information is helpful to those living with drug
-              users or to those wanting to know how to identify
-              symptoms of drug use, intervention methods,
-              and referral sources

## 2. Prevention Education and Skills Training   
    Programs   

   • More intensive (more hours per person) than  
     information dissemination programs

   • Cost more per participant

**    ****Programs**
-    • More intensive (more hours per person) than
-      information dissemination programs
-    • Cost more per participant

- Strengthening Schools, Families and Communities Approaches(Continued)

## 2. Prevention Education and Skills Training   
    Programs (Continued)

	             Examples

			• Life skills training
			• Peer and media resistance training
			• Classroom or small group sessions
			• Peer leader/helper programs
			• Children of substance abuse groups
			• Parenting and family skills training    
                        classes

		       • Youth or adult involvement in design and 
                    implementation helps (National Assembly,     
                   1994)

**    ****Programs (Continued)**
- 	             Examples
- 			• Life skills training
- 			• Peer and media resistance training
- 			• Classroom or small group sessions
- 			• Peer leader/helper programs
- 			• Children of substance abuse groups
- 			• Parenting and family skills training
-                         classes
- 		       • Youth or adult involvement in design and
-                     implementation helps (National Assembly,
-                    1994)

## The skills training or social competency approaches 

- behaviorally train students to resist pressures to use
- drugs and to learn social skills through three
- different strategies:
-  1) The Social Influences Approach involving
-       media persuasion resistance training and
-       peer resistance social skills training, used
-       in Project STAR, and I-STAR in the
-       Midwestern Prevention Project (Pentz
-       1983; Pentz, et al., 1989) and the
-       DARE program

## 	2. The Normative Education Approach which  
         encourages adoption of norms against drug use 
         and corrects inflated estimates found in youth 
         about the number of youth who actually use 
         drugs (Hansen, 1992; Hansen & Graham, 1991)  

	3. The Life Skills or Social Skills Approach (Botvin 
         and associates., 1990 (a,b,c)) teach youth how 
         to communicate, control stress and feelings of   
         anger or anxiety, restore self-concept,  choose 
         prosocial friends, increase social status, and 
         resist media and peer pressure to use drugs 

-          encourages adoption of norms against drug use
-          and corrects inflated estimates found in youth
-          about the number of youth who actually use
-          drugs (Hansen, 1992; Hansen & Graham, 1991)
- 	3. The Life Skills or Social Skills Approach (Botvin
-          and associates., 1990 (a,b,c)) teach youth how
-          to communicate, control stress and feelings of
-          anger or anxiety, restore self-concept,  choose
-          prosocial friends, increase social status, and
-          resist media and peer pressure to use drugs

## Intervention methods

-         1.	Demonstrations of effective and ineffective
-             behaviors
-         2.	Trainer demonstrations
-         3.	Participant role plays with feedback
- 	4. Reinforcement for changed behavior
-         5.	Role Modeling
- 	6. Positive peer group norms

## Results

- Modest reductions in onset and prevalence of
- cigarette smoking, alcohol, and marijuana use if:
- 	• Interactive classes better than lectures
- • Peer led classes better than teacher-led
-   classes
- • Some negative effects in students who
-   were already using

## Strengthening Schools, Families and Communities Approaches(Continued) 

- Including recreational, sports, cultural, and
- educational activities
- 	• Used with high-risk individuals because
-              of the increased cost
- 	• The theoretical justification is that providing
-               individuals with **"**alternative highs”
-               incompatible with substance use will
-               reduce use.

- Strengthening Schools, Families and Communities Approaches(Continued)

## 2.  Alternative Programs (Continued)

- • Also, some research supports a link between
-   sensation or thrill seeking personality and
-   drug use
-      Types
-  • Experiential Education Programs involving
-    wilderness experiences, ropes courses,
-    mountain climbing, rapelling, and rafting.
-  • Community Service Programs (removing
-    graffiti or developing community murals),
-    building homes, and volunteering to help
-    others  (Tobler, 1986)

## 2.  Alternative Programs (Continued)

- Examples
- 1. Amazing Alternatives was developed by
-     Murray and Perry (1985).
- 2. CSAP High-risk Youth Grants with
-     experiential education programs
- Results
-  • Effectiveness Unclear (Schaps and
-    associates (1981)
*	*

## Results (Continued)

- 	• Some alternative activities (academic,
-              religious, and active hobbies) decrease use
-              and others (entertainment, sports, social,
-              extracurricular, and vocational activities)
-              promote increased use
- • Critical ingredient is who youth associate
-   with in the activities

## Strengthening Schools, Families and Communities Approaches(Continued) 

- 	• Indicated prevention programs for drug
-              users or individuals showing mental health
-              symptoms of risk (e.g., delinquency,
-              aggression, depression, and other anti-social
-              behavior)
- 	• Strategies involve problem identification,
-              screening and referrals to special therapeutic
-              programs

- Strengthening Schools, Families and Communities Approaches(Continued)

## 4.  Intervention Approaches (Continued)

- Examples:
- • Student assistance programs
-   (Morehouse, 1979)
- • Peer counseling programs
- • Parent-peer groups for troubled youth
- • Teen hot lines and crisis intervention
-    (Tobler, 1986, 1992)

## Community Based Prevention

- Interventions

**1. Public Awareness and Media Campaigns**
- Results
- 	• Media campaigns do affect the community's
-              social norms when combined with other
-              community prevention strategies
-              (Wallach, 1985)
- 	• In addition, the public demand for credible
- 	  information about drugs is increasing and
-              should be satisfied by accurate and
-              scientifically credible messages

## 1. Public Awareness and Media Campaigns.

**    ****(Continued)**
- Examples
- 	• The Partnership for A Drug-free America
- 	   (1994) reports producing more than 400
- 	   anti-drug ads for their national campaign
- 	   worth $1.8 billion in media donations.
-               They were recently awarded advertising's
-               most prestigious award for effectiveness—
- 	   the Grand Effie

## Community Based Prevention

-     Implemented in community agencies serving
-     high-risk youth with the purpose of generally
-     improving youth development and outcomes.
-     Many of these selective or indicated prevention
-     programs are funded with CSAP or local county or
-     state funds from State Block Grant or state
-     legislative appropriations.

- Interventions (Continued)

## Community Based Prevention

- 	• The Botvin’s Life Skills Training Program:
-               a drug prevention curriculum implemented
-               in Philadelphia alternative Scholls was found
-               to increase knowledge about tobacco and
-               alcohol use, negative attitudes toward
-               marijuana use, and decrease school
-               problems, incidents of drunker aggression,
-               and legal problems.

- Interventions (Continued)

## 3. Social Interaction Skills Training Approaches:

-     (Continued)
- 	• The Smart Moves Program:  a drug prevention
-              curriculum based on the original pear
-              resistance skills training program was
-              implemented in public housing projects by
-              Boys and Girls Clubs.  Studies showed
- 	  that the presence of crack was lower in
-              developments served by Clubs with Smart
- 	  Moves (Schinke, Orlandi, and Cole 1992

## Community Based Prevention

-     Convey positive values, attitudes and life skills
-     through a one-to-one relationship with a positive
-     role model, who may be a culturally matched
-     community volunteer, college student, parent,
-     or business professional, or retired person.
- 	    Becoming very popular, currently this
-                approach is not as frequently used (found in
-                14% of the first 75 CSAP high-risk youth grants),
-                except as part of a more comprehensive program

- Interventions (Continued)

## Community Based Prevention

**  **  Tutoring programs reduce academic problems by
-     improving academic achievement.  Tutors can be
-     mentors, college students, grandparents,
-     professionals, or teachers to tutor students in
-     school or after school.

- Interventions (Continued)

## Community Based Prevention

**    **These programs focus on:
- 1. Responsibility training, skills training,
-     resiliency, community bonding, and spiritual
-     values

- Interventions (Continued)

## 6. Rites of Passage Programs (Continued)

** **Example:
- 	The Comprehensive Afro-American Adolescent
-            Services Project operated by the University of
-            Cincinnati included twenty 2-hour rites of
-            passage discussion groups with community
-            action projects and entrepreneurial training

## Critical Role of Families

- The family is the social unit primarily responsible for child  rearing functions.
- When families fail to fulfill this responsibility, the entire society suffers.
- Families are responsible for providing:
- Physical necessities
- Emotional support
- Learning opportunities
- Moral guidance
- Building self-esteem and resilience

## Slide 49

## CSAP Family PEPS (1998)

- 	Effective Family Intervention Strategies
- 	   1. Parent training
- 	   2.	Family skills training
- 	   3.	Family in-home support
- 	   4.	Family therapy

## Principles of EffectiveFamily-Focused Programs

- 1.	There Is No One Best Family-Focused Program.
-      • Select Programs Based On:
-   Ages of Children
-   Cultural Appropriateness
-   General Level of Family Needs (Universal
-       Low Risk Families)
- 	• Specific Family Needs.  Different Types of Family
-       Interventions Are Used to Modify Different Risk
-       and Protective Factors.

## Strengthening America’s Families

- Program Matrix

## Thirty-four Effective family intervention 

- programs can be found on web site
**www-medlib.med.utah.edu/healthed/ojjdp.htm **
**or call (801) 581-7718 at the University of **
**Utah Health Education Department**