Integrating Environmental Change Theory Into Prevention Practice

1
Integrating Environmental Change Theory Into
Prevention Practice

• Michael Klitzner, Ph.D.

2
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 healthincluding illicit drugs,
  alcohol, and tobacco

3
Strategies Targeting the Shared
Environment Support, Thwart
Strategies Targeting Individualized
Environments Socialize, Instruct, Guide, Counsel
Family
Norms
Regulations
School
ALL YOUTH
INDIVIDUAL YOUTH
Faith Community
Health Care Providers
Availability
4
Factors in the Shared Environment

• Norms
• Availability
• Regulations

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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

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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

7
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., HMOs,
  hospitality establishments, convenience stores)

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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

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A Basic Premise

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

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An Important However

• The Secretarys Initiative will focus largely on
  the shared environment for three reasons
• Efficiency
• Celerity
• Enhancement

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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

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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

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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)

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Enhancement

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

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Norms, Regulations, and Availability Play
Leap-Frog

• Norms, regulations, and availability are
  interdependent and mutually supportivethey
  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

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Concordant Evolution Change of degree rather than
type Incremental
Time 1
Time 3
NEWNorms
Norms
CHANGEDAvailability
NEW Regulations
Availability
Regulations
Time 2
NEWNorms
Availability
Regulations
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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

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Disconcordant Evolution Change of type rather
than degree Major/Precipitous
Time 3
Time 1
PREVIOUSRegulations
Regulations
UNCHANGEDAvailability
UNCHANGED Norms
Availability
Norms
Time 2
NEW Regulation
Availability
Norms
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1964 Surgeon Generals Report
1998
19701985
Norms
19501965
Norms
Smoking Is Sort of Dirty
Smoking Is a Form of Insanity
Ask before you light up
You SMOKE?????
Norms
Smoking Is Unremarkable
Cigarettes Are a Crutch
Cigarettes Are a Weapon of Mass
You can smoke anywhere
Ive tried quitting a
Destruction
hundred times
Smoking is the single greatest
Cigarettes Are Good
Im giving Luckies to all my
threat to the health of our Nation
Smoking Is Dangerous to
friends this Xmas
Smokers
Smoking Is Dangerous to Everyone
No Need To Worry
Well, if he wants to kill
Everyone knows that secondhand
Not a cough in a carload
himself . . .
smoke causes . . .
Availability
Availability
Cigarettes Are
Cigarettes Are Not on
Availability
Everywhere
Display
Cigarettes Are Expensive
Look in the crystal box on
Whatever happened to
the coffee table
our silver table lighter?
Smokers Are Hidden
Isnt that Dr. Horowitz
Cigarettes Are Cheap
Cigarettes Are Not
smoking behind the
Can I borrow a quarter for
Offered
dumpster?
a pack of Camels?
Should a gentleman offer
a lady a Lucky? No!
Regulations
Regulations
No-Smoking Areas, Period
Smokey the Bear
Welcome to Our TownA
Regulations
Dont throw a lighted
smoke-free city
No-Smoking Areas
cigarette from your car in a
Smoking or non-smoking?
dry forest
Suits Against Tobacco
Companies
Fines for Smoking
but . . .
You will be subject to a
No-Smoking Bars????
fine of 25
NO WAY!!
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19501965
Norms Smoking is Unremarkable You can smoke
anywhere Cigarettes are Good Im 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 Dont throw a lighted
cigarette from your car in a dry forest
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19701985
Norms Smoking is Sort of Dirty Ask before you
light up Cigarettes are a Crutch Ive 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 25
fine
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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 Isnt that Dr. Horowitz smoking behind the
dumpster?
Regulations No-Smoking Areas, Period Welcome to
Our TownA smoke-free city
Suits Against Tobacco Companies but . .
. No-Smoking Bars???? NO WAY!!
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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

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Table 1
Associated Regulations
Associated Availability Issues
Associated Norms
Strategy
Primary Focus
Needed Resources
Concerned Parent Groups/Safe Homes Coalitions
Reinforce norm that parents can and should
monitor childrens 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
Highly motivated volunteers to organize and
sustain effort Communications and surveillance
equipment
Community members are responsible for community
well-being Illicit drugs are destructive to
individual and community
Citizen Surveillance
Reduce availability of illicit drugs by making
neighborhood riskier for dealers
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.
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Approaches

• Science-Based Approaches
• Logic-Based Approaches
• Symbolic Approaches

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Science-Based
Logic-Based
Alcohol

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

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

Illicit Drugs

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

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

Tobacco

• 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)

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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

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Pre-Dissemination
Phase
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

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Dissemination
Phase
Goals
Targets are aware of the program/strategy/policy
Factors

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

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Conversion
Phase

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

Goals

• 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

Factors
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Adoption
Phase
Targets are committed to trying the
program/strategy/policy
Goals

• 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

Factors
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Implementation
Phase
Goals
Targets successfully implement the
program/strategy/policy goals

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

Factors
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Reality
Myth
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-businessthey 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.