Since 1991, after a relative hiatus of several years, drug use, including tobacco and marijuana use, among U.S. adolescents has been on the increase, and more recently, illicit drug use as a whole (Johnston et al. 1995). The question is, why?
One major hypothesis is that after a decade of intense public attention to the youth drug use problem, the U.S. public may have experienced burnout (Johnston 1996, pp. 17-18; Bachman et al. 1990). The intense focus of attention has been indicated by national mass media coverage, special attention to drug abuse education in schools, and an influx of Federal dollars for prevention research and demonstration projects. The burnout manifests itself as the antithesis of indicators of public attention: low mass media coverage, poorer implementation of and lower budgets for drug education in schools, and loss of Federal dollars for prevention education research. These funds have been appropriated elsewhere to novel areas of public interest, such as violence, and underserved populations, and minority and rural populations of youth.
Decreased attention to universal drug abuse prevention, that is, specific drug abuse prevention and education for all youth, may increase drug use by sending an inadvertent message to youth that drugs are either more tolerated or less prevalent (perceived social norm) or not as harmful as previously thought (perceived personal risk, Bachman et al. 1990). Sustained reversal of the attentional problem and related drug use mediators may depend on a community-based approach to drug abuse prevention. This would necessitate a comprehensive programmatic and policy intervention strategy integrating multiple, varied community intervention channels that together and over time are most likely to reinforce youth prevention practices and promote non-use social norms in the community.
Several questions arise in consideration of a community approach to drug abuse prevention compared with single or smaller channel approaches such as school or parent programs. First, on a general level, should a community adapt or tailor a strategy based on previous research and theory or develop a new strategy? The former decision assumes a consistent set of behavior change principles and results that can generalize across communities; the latter assumes that each individual community is unique and that a community's leaders should fashion a prevention program based solely on their own perceived needs and preferences.
A second general question is whether community leaders should organize and develop a prevention program according to a formal, agreed-on process, meet briefly to catalyze others' efforts to promote drug prevention, or meet initially and let the chips fall where they may. The first decision would be based on research, the second on an assumption of community reactivity, and the third on no assumption.
Finally, in general, should a community develop a structure according to which certain identified parties are held responsible for program planning, training, implementation, and evaluation, or should these activities be dependent on the availability and interest of volunteers? Again, the first decision is based on research, the second on existing resources.
In addition to general questions that will define a community's overall approach to drug abuse prevention, several specific questions arise. These questions are most likely to be raised by the parties in the community who perceive themselves as decisionmakers for a prevention program. First, what components or ingredients of a community program can produce a significant change in drug use behavior? Second, how large is a significant effect, and will this effect be interpreted as meaningful by the community? Third, is continuous programming across different ages and grade levels required to sustain a long-term program effect? The community can address all of these specific programmatic questions by referring to previous research. Where research is lacking, comprehensive theories of behavior change can guide a community's decision to adopt a particular prevention program or strategy.
Review of Theory
Person-level (P) theories of behavior change suggest that programs aimed at changing personal attitudes about, and the value and consequences of, drug use are more likely to change individual drug use behavior than are those aimed at changing knowledge or at providing information about drugs (Ajzen and Fishbein 1990). Added to this are theories of cognitive problem solving and intentions, which suggest that skills training and public commitments against drug use can change an individual's decision and intentions to use drugs (Petraitis, Flay, and Miller 1995).
Situation-level (S) theories of behavior change are those that focus on changing interpersonal and group behavior. The most effective among these for changing drug use behavior by youth are the social influence theories, including social learning theory, self-efficacy theory, and social normative expectancy value theory (Bandura 1977; Rotter 1954). These theories suggest that drug use behavior can be prevented or changed by teaching youth how to avoid or counteract social pressures, such as group peer pressure, to use drugs and how to correct perceived social norms for drug use. These theories further suggest that interactive program implementation methods are more likely to change behavior than didactic methods.
Environment-level (E) theories suggest that changing the community norms for drug use, enabling diffusion of prevention programs and messages, and empowering community leaders to take responsibility for drug use prevention are the means by which prevention programs are likely to effect changes in drug use behavior, particularly over the long term. These theories include diffusion of innovation, organizational change, mass communication, and empowerment theories (Rogers and Storey 1987, pp. 817-846; Pentz 1986; Goodman et al. 1996).
All three levels of these theories should be integrated in the conceptualizing, design, implementation, and evaluation of community drug abuse prevention programs. P-level theories explain how the norms, attitudes, and behaviors of individuals can be changed. Programs based on these theories, if implemented with successively larger groups and populations, are likely to change perceived group norms and actual community norms as well, according to S- and E-level theories. Programs incorporating S-level theories build peer and family support for prevention practices. Incorporating E-level theories extends drug use prevention messages, norms, support, and resources to the community. E-level theories also improve the likelihood that programs will be maintained or institutionalized over the long term.
A community-based drug abuse prevention program based on an integrated P 5 S 5 E theoretical model would most likely include the use of multiple program channels that represent P, S, or E levels of influence on youth, including school, family or parents, community organization, mass media, and policy (Pentz 1986; Pentz 1994a). According to an integrated theoretical model, use of these program channels would be staged or sequenced into the community to maximize initial learning, boost learning effects, diffuse prevention support, and maintain public interest.
In addition to a theoretical model of behavior change, the complexity of mounting a communitywide drug abuse prevention effort requires attention to theories pertaining to organizational process (that is, the process by which a community can adopt, implement, and maintain a program) and structure (that is, the structure developed to promote and take responsibility for this process). Organizational theories relevant to community prevention programming suggest that a process with identifiable time-limited steps or objectives to be completed empowers community leaders to implement a program efficiently; such a process should include conjoint feedback and evaluation at each step before the next step is addressed (Goodman et al. 1996; Pentz 1986). Relevant structural theories suggest that community leaders form a council or coalition with several committees organized by responsibility for specific drug use risk factors such as drug accessibility, or by program channels such as mass media (Boruch and Shadish 1983; Pentz et al. 1989).
Review of Research
The development of a community drug abuse prevention program should be guided by previous research as well as by theory. Research incorporating one or more program channels relevant to community-based youth drug abuse prevention were reviewed. The review was restricted to published studies appearing in PsycINFO and MEDLINE searches, and in three cases, studies whose recent results are under review for publication. A total of 20 prevention studies and 4 reviews representing 96 community demonstrations resulted. Studies are summarized by type (tobacco, alcohol, other drug, heart disease or cancer with smoking component), evidence of use of theory (yes or no), research-based programs (yes or no), evaluation of process (yes or no), formal community structure organization (yes or no), and program components (mass media, school, family, community organization, policy change). Results are shown in table 1.
Of the 24 studies and reviews, 10 (42 percent) relied on a theoretical model of behavior change; 16 (67 percent) relied on previous research to guide program development. Five (21 percent) used a process model to guide development of a coalition or program planning, and 62 percent used a structure or structural model to develop planning responsibility. Overall, reliance on previous research was associated with more changes in drug use behavior than reliance on theory, process, or structure, although most research-based studies also included theory, process, and structure.
Based on youth-related experiences of the heart health trials, multicomponent community-based programs should include substantial school programming to initiate behavior change in conjunction with a community organization structure and process that promotes mass media programming and coverage, parent and adult education, and informal or formal policy change (Mittelmark et al. 1993). A standard for comparison might be the 2- to 15-percent short-term decreases found in school-based studies of smoking prevention (Pentz 1995).
Among studies with a community component alone, the two studies involving Boys and Girls Clubs educational programs and activities both showed significant short-term decreases in cigarette, alcohol, and marijuana use compared with short-term decreases reported for school-based programs (see Schinke et al. 1992; St. Pierre et al. 1992; Pentz 1994b). Three studies of coalitions showed that community or organization without education was ineffective overall in changing drug use behavior.
Overall, results of programs that included one or more community program components with a school educational program showed short-term effects on monthly smoking and drug use similar to those of comprehensive school programs that included a large number of sessions and boosters (see Botvin et al. 1995). However, the effects of school plus community programs appeared to have a greater range of effects and larger long-term effects on heavier use rates, averaging 8 percent net reductions (Pentz 1995). Community programs with a school component were the only programs to show any effects on parent behavior.
Thirteen (54 percent) of the studies and reviews included some type of community organization or education with a school program. For example, 10 studies (42 percent) combined parent involvement through education or homework with a school program (Eggert et al. 1990; one review of four studies in Flay et al. 1985, 1995; Perry et al. 1992; Barthold et al. 1993; Shea et al. 1992; Stevens et al. 1993; Perry et al. 1993; Murray et al. 1994; Pentz 1993). Five of these suggested that parent involvement increased effects on youth health behavior; three studies suggested that parent involvement increased effects on parents.
Thirteen studies (54 percent) included a mass media component. Three of these suggested that media changed parent behavior (Flay et al. 1985; Flynn et al. 1992; Pentz 1993).
Several (29 percent) of the studies included some informal or formal policy change component (Perry et al. 1992; Barthold et al. 1993; Shea et al. 1992; Stevens et al. 1993; Perry et al. 1993; Hingson et al. 1996; Center for Substance Abuse Prevention 1996). Policy change mostly involved reducing youth access to substances and controlling product availability. Effects of policy independent of other components could not be determined.
Six studies (one a review) directly compared a school program component with parent and/or mass media components (Flay et al. 1995; Flynn et al. 1992; Kaufman et al. 1994; Murray et al. 1994; Stevens et al. 1993). Overall, these studies showed greater effects on youth drug use when community intervention included a school program and when school programs included parent and/or mass media programs.
In 1984 a comprehensive community-based drug abuse prevention trial, the Midwestern Prevention Project (MPP), was initiated in Kansas City; in 1987 a replication was initiated in Indianapolis. In both cities, by design, the native program implementation period extended through 1991. Since 1991 approximately 25 percent of Kansas City schools have retained the school program component; over 80 percent of Indianapolis schools and communities have retained the school, parent, and community program components. In both cities, retention of programming after 1991 represents institutionalization of a theory- and research-based program by the community with its own funds and resources.
Adolescents entering middle school (sixth grade) or junior high school (seventh grade) in fall 1984 in Kansas City and in fall 1987 in Indianapolis were the study population. From the transition cohort, approximately one-third of the population was randomly selected by classroom from each school and recruited for study participation with parental consent. More than 90 percent participated. The results summarized in this paper are based on two of multiple samples studied: a grade cohort sample that included a panel (N=5,400, N=50 schools, Kansas City), and a panel sample (N=3,192, N=57 schools, Indianapolis). The study population was approximately 70 percent white, 23 percent African American, and 7 percent other.
Research and Measurement Designs
Schools within each community (N=26) were assigned to an intervention or delayed intervention control condition, a two-group design. Because the MPP in Kansas City started after the school year began, assignment of all but 8 of the 50 schools was based on administrator ability to change schedules; the remaining 8 were randomly assigned. All 57 schools in Indianapolis were randomly assigned to the program or control condition. The measurement design was longitudinal, with students administered a survey and a comeasure at baseline and each year.
Three models were used to develop the MPP: (1) the P (person) ´ S (situation) ´ E (environment) transactional theoretical model, on which hypotheses, measures, program content, and implementation were based; (2) the 10-step organizational process model, used to integrate research and local program planning, organize community leaders, and evaluate program planning and implementation; and (3) a structural model, used to organize, sequence, and assign responsibility for a community needs assessment, community organization training program implementation, and evaluation (Pentz, in press; Pentz 1986; Pentz et al. 1989; Pentz 1993). These are shown respectively as figures 1, 2, and 3.
|FIGURE 1. The P x S x E transitional theoretical model
SOURCE: Reprinted with permission. M.A. Pentz, CSAP NPERC Prevention Evaluation Report, in press.
The MPP community-based intervention, referred to locally as Project STAR or I-STAR, targeted avoidance and reduction of drug use, with special emphasis on prevention of cigarette, alcohol, and marijuana use in middle/junior high school. Five program components were implemented: (1) mass media coverage, promotional videotapes, and commercials about each program component; (2) an 11- to 13-session school program with 6 homework sessions with parents followed by a 5-session booster school program with 3 homework sessions; (3) a parent organization program involving parent-principal meetings and parent-child communications training; (4) a community organization program to organize and train community leaders to develop action groups; and (5) drug use policy change. Content and implementation methods for all program components were derived from several theories, including social learning theory (Bandura 1977), training resistance skills through the use of modeling, rehearsal, feedback with Socratic discussion, reinforcement, and extended practice; attribution and value expectancy theories (Azjen and Fishbein 1990), correcting perceptions of social consequences of drug use and social normative expectations about drug use; cognitive development theories, making public commitments to avoid drug use; preparing for school and developmental transitions (Pentz 1994b); communication theories (Rogers 1987) promoting positive parent-child and mass media communication; and social support. The order and phasing of program components, with one component introduced into communities at the rate of 6 months to 1 year apart, were based on diffusion of innovation and other mass communication theories (Rogers 1987).
The mass media program component focused on disseminating information about other program components to the public at large, presenting brief prevention skills, and presenting messages targeted to youth and parents. The mass media component included an average of 31 television and print media segments each year beginning in the first year.
|FIGURE 2. The 10-step organizational process model
SOURCE: Reprinted with permission. M.A. Pentz, J Sch Health. Copyright 1986.
The school program component focused on training students how to recognize and counteract social influences to use drugs, including peer pressure, drug use modeling by parents and other adults, and glamorized portrayals of drug use in ads and mass media programs. The school program was implemented by trained teachers and student peer leaders in regular science or health education classes in 18 classroom sessions over the first 2 years.
The parent program component focused on developing a comprehensive school drug abuse prevention policy, deterring drug use on and near school grounds, and training parents in parent- child communication and prevention support skills through a series of organizational meetings and activities. The parent program was implemented by a core group of trained principals, two to four parents, and two student peer leaders in each school who met throughout each school year in the second and third years.
|FIGURE 3. A structural model used to organize, sequence, and assign responsibility for program development
SOURCE: Reprinted with permission. M.A. Pentz, et al. JAMA. Copyright 1989.
The community organization component focused on identifying and training community leaders in drug abuse epidemiology and prevention. The organization developed citywide campaigns for drug abuse prevention to complement and reinforce prevention messages delivered in the other program components, facilitated referral and information networks among drug abuse prevention and treatment agencies, and supported and extended public education about the program to population groups not directly targeted by the other program components. Following the Minnesota Heart Health Project and other similar community organization models (Mittelmark et al. 1993), community leaders were organized as a council with eight action committees designed to develop and implement prevention initiatives according to youth-serving function (legislative, worksite, health/medical, educational, religious, youth social service/recreational, parental, and treatment [Mansergh et al. 1996]). The action committees met every 4 to 6 weeks, beginning in the third year. Beginning in the fourth year, the policy component used the parent program committee from each school and the community organization to review and refine school drug-free zone policies, develop restricted use and access policies for youth at the community and city levels, develop mandates for funding youth prevention and treatment services, and lobby for a beer tax.
A multiform questionnaire was administered in the classroom to all subjects by trained project data collectors who were independent of program implementation or training (average N of items = 116). Subjects were measured at baseline and at annual followups.
The questionnaire assessed frequency and amount of tobacco, alcohol, and marijuana use and other illicit drug use; psychosocial variables related to drug use, including use by peers and parents; and demographic characteristics. Immediately preceding questionnaire administration at baseline and each followup, carbon monoxide (CO), a byproduct of cigarette and marijuana smoking, was measured with a MiniCo Indicator (Catalyst Research Corp., Owings Mills, MD). The CO measure was used as a "pipeline" to increase the accuracy of self-reports of drug use.
Several alternative statistical models were used to estimate program effects, including conditional (covariance) and unconditional (change score or repeated measures) models; linear regression with school as the unit of analysis and logistic regression with the individual as the unit of analysis; ordinary least squares estimation and weighted least squares estimation adjusting for differences in individual school sample sizes. Findings were similar across the alternative approaches. The results summarized here focus on ordinary least squares estimates, with school as the unit of analysis to match the unit of intervention.
The general pattern of program effects through the end of high school is shown in figure 4, using unadjusted data on cigarette smoking in Kansas City as an example (Pentz 1993). Effects of the community-based program on cigarette, alcohol, and marijuana use have maintained beyond the end of high school and into early adulthood. Similar to comprehensive school programs involving many sessions and boosters, the MPP showed average decreases of 8 to 15 percent in cigarette and marijuana use, or a 20- to 40-percent net program effect, for the 3 years associated with program participation by students. Beyond the 3-year mark, the MPP showed greater and more sustained effects on heavier use rates than those reported by school or other single channel programs, including an average reduction of 4 percent in daily cigarette use, monthly drunkenness, and heavy marijuana use two or more times in the preceding week (Botvin et al. 1995).
Beyond the end of high school, effects have emerged on the use of some stimulant classes of drugs, including amphetamines and cocaine, but not on depressants.
The following questions serve as directions for future research, answers to which could improve future community prevention practices.
|FIGURE 4. Midwestern Prevention Program effects on unadjusted cross-sectional prevalence rates of daily cigarette use in Kansas City as an example
SOURCE: Reprinted with permission. M.A. Pentz, CSAP NPERC Prevention Evaluation Report, in press.
Is school plus community better than school or community alone? This paper suggests that, overall, yes, it is. However, a more definitive answer depends on studies using research designs that directly compare these components.
Are school-plus-community programs replicable? Given the consistency of positive findings of school-plus-community programs on youth and parent behavior, the general answer appears to be yes. However, communities show great variability in the structure and action plans of a coalition, council, core team, or task force component used to plan drug prevention. This type of component may not be replicable in a standardized fashion but could be evaluated as part of a qualitative or quantitative process and implementation analyses, as the Robert Wood Johnson and Center for Substance Abuse Prevention studies have attempted.
Is school-plus-community research feasible with multiple communities? Several methodological papers have indirectly addressed this question (e.g., Boruch and Shadich 1983, pp.73-98; Goodman et al. 1996; Manger et al. 1992; Pentz 1994a; Koepsell et al. 1992; Wiener et al. 1993). The demographics and past drug use behavior of communities are difficult to match, suggesting that a large number of communities would be necessary for randomizing to experimental conditions, with the community as unit. Such a study is expensive. Most of the studies reviewed here included multiple community components versus a control or delayed intervention control group. The ability to evaluate the effects of separate components in a community intervention would require the use of a factorial design, in which effect size associated with each component intervention or sets of components compared with each single component intervention would be assumed to be significantly different. Only a few studies have had cell sizes large enough to detect differences between interventions or components of interventions (e.g., Flynn et al. 1992; Flay et al. 1995).
Are school-plus-community programs cost-effective? A recent analysis of the prototype-integrated school health education programs included projected costs and reported outcomes from seven comprehensive school-based programs and two school-plus-community programs (Rothman 1995). Results indicated that annual costs per student for program delivery ranged from $10 to $35. Effects, measured as percentage of net reduction between program and control groups, ranged from 6 to 9 percent. The benefit-to-cost ratio was 19 for smoking. A recent analysis of a school-plus-community program for drug abuse prevention supports these findings (Pentz 1996, pp.1-22).
Over the long term, who should coordinate school-plus-community programs, and who would fund these programs? The research studies reviewed here varied in terms of who was responsible for coordinating programming, including research staff members, health educators, school personnel, and paid and volunteer community leaders. None of the studies systematically compared the effectiveness of types of coordinators (see Goodman et al. 1996). A major question is whether coalitions that draw from community leaders but are organized by the school or school district generate more or less credibility and cooperation than coalitions that draw from community leaders and are organized by the community. The studies reviewed here showed the latter, but no comparisons with the former were made. If coalitions are used to coordinate school health education, then community agencies and Federal and State funds that are allocated to community agencies for health services might be used to augment existing school drug education budgets. However, if school-based health advisory councils are used, then accessing community health care funds may be difficult and resented. A long-term alternative would be qualifying school health clinics and health education as a managed health care service delivery organization, reimbursable by insurance and Federal funds (Pentz 1995). In this case, managed care funds could be combined with existing school health education funds to create a unified funding package for school health education. As long as health care reimbursements were forthcoming, this alternative should be more stable than relying on the graces of volunteered community agency funds.
Can integrated school-plus-community programs affect educational outcomes as well as health outcomes? Comprehensive school programs that included more than seven sessions, booster sessions, standardized training, and monitoring of implementation, had substantial effects on knowledge change, as did school-plus-community programs; no substantial differences were apparent. To the extent that knowledge is meas-ured as an educational outcome in health education classes, comprehensive school programs and integrated school-plus-community programs could be considered effective in improving educational achievement. However, no studies reported a health program having significant effects on grade point average, absenteeism, or dropout rates, which are considered key indicators of educational achievement.
A review of multiple studies suggests that a community prevention program can vary in the use of mass media, parent programs, community education and organization, and local policy change. Results suggest that community-plus-school programs may yield greater effects on the more serious levels of drug use (e.g., on daily smoking compared with monthly smoking), effects on parents as well as youth, and perhaps more durable effects than are currently obtainable from most school programs alone. Overall, the magnitude of effects on smoking and substance use appears slightly greater for school-plus-community versus school programs alone (6- to 8-percent net reductions).
The review of studies points to several gaps in the literature, which should serve as directions for future research. These include the following:
- More systematic evaluation of the cost-benefit and cost-effectiveness of school and school-plus-community programs that rely on true costs
- Evaluation of the efficacy of extensive school programming alone (i.e., 30 sessions or more with boosters delivered over several years) versus the same school programming with additional community components, with school district/community as the unit of assignment and analysis if possible
- Comparison of school-plus-community programs that vary in intensity or type of community involvement.
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