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Module IX: CommunityBased Substance Abuse Prevention

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Title: Module IX: CommunityBased Substance Abuse Prevention


1
Module IX Community-Based Substance Abuse
Prevention
Project MAINSTREAM
November 2005
2
Learning Objectives
  • Health Care Professionals will be able to
  • Define community-based prevention.
  • Discuss types and levels of prevention.
  • Compare frameworks for preventive interventions.
  • Identify risk and protective factors associated
    with substance use disorders.
  • Cite theories of behavioral change.
  • Discuss cultural influences on prevention.

3
Learning Objectives (continued)
  • Health Care Professionals will be able to
  • Define the role of the health care professional
    in prevention.
  • Discuss general and specific strategies for
    community-based prevention.
  • Identify evaluation aims for community-based
    prevention programs.

4
Introduction
  • Substance use disorders take greater toll than
    any other preventable health problem.
  • Substance use disorders occur across the
    lifespan.
  • Communities are appropriate sites for preventive
    interventions.

5
Definition of Prevention
  • Prevention is a proactive process that empowers
    individuals and systems to meet the challenge of
    life events and transitions by creating and
    reinforcing conditions that promote healthy
    behaviors and lifestyles.
  • (CSAP, 1994)

6
Prevention Activities Classified
  • Approach (demand vs. supply reduction)
  • Levels of prevention
  • Universal
  • Selective
  • Indicated
  • Focus (direct vs. indirect)

7
Mental Health Approach to Prevention
  • Universal Preventive Intervention
  • Desirable for everyone in eligible population.
  • Selective Preventive Intervention
  • Targeted for individuals or subgroups at
    significantly higher risk than average.
  • Indicated Preventive Intervention
  • Targeted for high-risk individuals with minimal
    but detectable signs/symptoms.

8
The Mental Health Intervention Spectrum
Treatment
Standard Treatment for Known
Disorders
Case Identification
Maintenance
Prevention
Indicated
Compliance with Long-term Treatment
(Goal Reduction in Relapse and Recurrence)
Selective
After-care (Including Rehabilitation)
Universal
9
Examples of Research-Based Drug Prevention
Programs
  • Life Skills Training (Botvin, et al., 1990)
  • Project STAR (Pentz, et al., 1989)
  • Strengthening Families Program (Kumpfer, et al.,
    1994)
  • Reconnecting Youth Program (Eggert, et al., 1994)

10
Approaches to Community-Based Prevention
  • Clinical perspectivefocus on individual factors
    and lifestyle issues
  • Public health perspectivefocus on law, policies
    and practices that affect production, marketing
  • CombinedProject Northland

11
Frameworks for Community-Based Prevention
  • Preventive Intervention Research Cycle
  • PRECEDE - PROCEED
  • SAMHSA Prevention Platform

12
Prevention Intervention Research Cycle
1. Identify problem or disorder(s) and review
information to determine its extent.
2 With an emphasis on risk and protective
factors, review relevant information - both from
fields outside prevention and from existing
intervention research programs.
4. Design, conduct, and analyze large-scale
trials of the preventive intervention program.
5. Facilitate large-scale implementation and
ongoing evaluation of the preventive intervention
program in the community.
3. Design, conduct, and analyze pilot studies
and confirmatory and replication trials of the
preventive program.
13
PRECEDE - PROCEED Model
  • Phase 1 Social assessment Consideration of
    quality of life by determining subjectively
    defined problems of individuals and communities.
  • Phase 2 Epidemiological assessment
    Identification of specific health goals or
    problems that may contribute to social goals
    (disability, discomfort, fertility, fitness,
    morbidity, mortality, physiological risk
    factors).
  • Phase 3 Behavioral and environmental
    assessment Identification of behavioral factors
    (compliance, consumption patterns, coping,
    preventive actions, self care, utilization) and
    environmental factors (economic, physical,
    services, social).

14
PRECEDE -PROCEED Model (continued)
  • Phase 4 Educational and organizational
    assessment Identification of predisposing
    factors (knowledge, attitudes, beliefs, values,
    perceptions), reinforcing factors, attitudes and
    behavior of health and personnel, peers, parents,
    employers, and enabling factors (availability of
    resources, accessibility, referrals, rules, laws,
    skills).
  • Phase 5 Administrative and policy assessment
    Assessment of organizational and administrative
    capabilities and resources, for development and
    implementation of a program.
  • Phase 6,7,8,9 Implementation and process,
    impact and outcome evaluation.

15
SAMHSA Prevention Platform
  • The SAMHSA Prevention Platform is an online
    resource designed to assist professionals and
    community volunteers to engage in substance abuse
    prevention. The framework includes the following
    areas
  • Assessment determining your prevention needs.
  • Capacity improving your capabilities.
  • Planning developing a strategic plan.
  • Implementation putting your plan into action.
  • Evaluation documenting the outcomes of your
    work.
  • (Http//preventionplatform.samhsa.gov)

16
Model
17
Lessons from Prevention Research
  • Sixteen
  • Evidence-Based Principles

18
Principle 1
  • Prevention programs should enhance protective
    factors and reverse or reduce risk factors

19
Principle 2
  • Prevention programs should address all forms of
    substance abuse alone or in combination

20
Principle 3
  • Prevention programs should address the type of
    drug abuse problem in the local community, target
    modifiable risk factors, and strengthen
    identified protective factors

21
Principle 4
  • Prevention programs should be tailored to address
    risks specific to population or audience
    characteristics

22
Principle 5
  • Family-based prevention programs should enhance
    family bonding and relationships and include
    parenting skills practice in developing,
    discussing, and enforcing family policies on
    substance abuse and training in drug education
    and information

23
Principle 6
  • Prevention programs can be designed to intervene
    as early as preschool to address risk factors for
    drug abuse, such as aggressive behavior, poor
    social skills, and academic difficulties

24
Principle 7
  • Prevention programs for elementary school
    children should target improving academic and
    social-emotional learning to address risk factors
    for drug abuse, such as early aggression,
    academic failure, and school dropout. Education
    should focus on the following skills

25
Principle 7 (continued)
  • self-control
  • emotional awareness
  • communication
  • social problem-solving and
  • academic support, especially in reading

26
Principle 8
  • Prevention programs for middle or junior high and
    high school students should increase academic and
    social competence with the following skills

27
Principle 8 (continued)
  • study habits and academic support
  • communication
  • peer relationships
  • self-efficacy and assertiveness
  • drug resistance skills
  • reinforcement of anti-drug attitudes and
  • strengthening of personal commitments against
    drug abuse.

28
Principle 9
  • Prevention programs aimed at general populations
    at key transition points, such as the transition
    to middle school, can produce beneficial effects
    even among high-risk families and children. Such
    interventions do not single out risk populations
    and, therefore, reduce labeling and promote
    bonding to school and community

29
Principle 10
  • Community prevention programs that combine two or
    more effective programs, such as family-based and
    school-based programs, can be more effective than
    a single program alone

30
Principle 11
  • Community prevention programs reaching
    populations in multiple settingsfor example,
    schools, clubs, faith-based organizations, and
    the mediaare most effective when they present
    consistent, community-wide messages in each
    setting

31
Principle 12
  • When communities adapt programs to match their
    needs, community norms, or differing cultural
    requirements, they should retain core elements of
    the original research-based intervention

32
Principle 13
  • Prevention programs should be long-term with
    repeated interventions (i.e., booster programs)
    to reinforce the original prevention goals.
    Research shows that the benefits from middle
    school prevention programs diminish without
    follow-up programs in high school

33
Principle 14
  • Prevention programs should include teacher
    training on good classroom management practices,
    such as rewarding appropriate student behavior.
    Such techniques help to foster students positive
    behavior, achievement, academic motivation, and
    school bonding

34
Principle 15
  • Prevention programs are most effective when they
    employ interactive techniques, such as peer
    discussion groups and parent role-playing, that
    allow for active involvement in learning about
    drug abuse and reinforcing skills

35
Principle 16
  • Research-based prevention programs can be
    cost-effective. Similar to earlier research,
    recent research shows that for each dollar
    invested in prevention, a savings of up to 10 in
    treatment for alcohol or other substance abuse
    can be seen

36
Risk and Protection Factors
37
Risk Factors
  • Indicators for potential problem occurrence or
    vulnerability
  • Characteristics that occur more often for those
    who develop substance use problems

  • (NCADI, 1990)

38
Protective Factors
  • Presence of positive influences
  • Not merely absence or opposite of risk factors
  • (NCADI, 1990)

39
Resilience
  • An ability to recover from or adjust easily to
    misfortune or change (Webster)
  • Successful adaptation despite risk and adversity
    (Wolin and Wolin, 1995)
  • Protective factors lead to resilience

40
Six Life Areas
  • Individual
  • Family environment
  • Peer association
  • School/work-related
  • Community environment
  • Society-related

41
Risk Factors
  • Genetic/biomedical factors
  • Attitudes and predispositions
  • Perception of risk

Personal/Individual
42
Risk Factors (continued)
Personal/Individual
  • Other predispositions
  • Impulsivity
  • Hostility
  • Rebelliousness
  • Deficits in social skills
  • Early aggression
  • Alienation

43
Risk Factors (continued)
  • Personal/Individual
  • Problem Behaviors
  • Juvenile delinquency
  • Violence
  • Teen pregnancy
  • Dropping out of school

44
Protective Factors
  • Personal/Individual
  • Good social skills
  • Caring and cooperative
  • Positive sense of self
  • Problem-solving skills
  • Sense of humor
  • Autonomy and purpose
  • Genetics/biomedical factors
  • Pro-social bonding

45
Protective Factors (continued)
  • Personal/Individual
  • Genetically controlled variation of aldehyde
    hydrogenase (ALDH2), called ALDH2-2, in 10 of
    Asians creates intense reaction to alcohol.
  • Lower alcoholism risk is also associated with
    genetically controlled variants of alcohol
    dehydrogenase (ADH2, ADH3) in Asians and several
    other ethnic groups

  • (Schuckit, 1999)

46
Risk Factors
  • Family
  • Abusive or conflict-ridden families
  • Economic deprivation
  • Reduced supervision
  • Limited formal controls
  • Limited social supports
  • Poor family discipline, and problem-solving

47
Risk Factors (continued)
  • Family
  • Parental use of alcohol and drugs
  • Parental positive attitudes toward substance use

48
Protective Factors
  • Family
  • Positive bonding
  • Lack of severe criticism
  • Basic trust
  • High parental expectations
  • Clear rules
  • Parental involvement in activities
  • Involvement in religious institutions

49
Risk Factors
  • School
  • Substandard academic environment
  • A negative, disorderly, and unsafe school climate
  • Low teacher expectations of student achievement

50
Protective Factors
  • School
  • Caring and support
  • High expectations
  • Clear standards and rules
  • Youth participation in tasks and decisions

51
Risk Factors
  • Peer Group
  • Negative influence of peers
  • Involvement with friends who use alcohol and
    drugs
  • Involvement with peers who engage in other risky
    behaviors

52
Protective Factors
  • Peer Group
  • Positive peer group activities
  • Positive peer group norms
  • Peer groups with skills to resist negative
    influences
  • Peer groups with good decision-making skills

53
Risk Factors
  • Community
  • Community norms that promote or permit substance
    use
  • Poverty
  • Community disorganization
  • Cultural disenfranchisement

54
Risk Factors (continued)
  • Community
  • Customs/policies that encourage substance use
  • Pro-use messages in the general media.
  • Pro-use targeted promotion
  • High availability of substances

55
Protective Factors
  • Community
  • Caring and support
  • High expectations
  • Opportunities for participation
  • Presence of effective prevention programs
  • Laws/norms that discourage substance use

56
Risk Factors
  • Societal
  • Availability of substances
  • National conditions
  • Poor economy and unemployment
  • Discrimination and marginalization
  • Media messages

57
Protective Factors
  • Societal
  • Teaching children about media messages
  • Counter-advertising messages
  • Decreasing substance availability/accessibility

58
Risk Factors for the Elderly
  • Polypharmacy
  • Increased biologic sensitivity to substances
  • Negative coping responses
  • Change in role status
  • Change in health status
  • Loss

59
Risk Factors for the Elderly (continued)
  • Loneliness
  • Boredom
  • Lack of social support
  • Depression
  • (Marcus, 1993 Schonfeld Dupree, 1991
    Fingerhood, 2000)

60
Protective Factors for the Elderly
  • Positive coping responses to life changes
  • Supportive family
  • Supportive social networks
  • Aware of drug interactions and potential for
    biologic sensitivity to substances
  • (Welte Mirand, 1995 Simoneau
    Bergeron, 2000)

61
Role of the Health Care Practitioner
  • In the clinical area
  • To identify people who have risk factors
  • To build protective factors by giving healthy
    prevention messages
  • To set up the office space to promote health and
    prevent substance use problems.

62
Role of the Health Care Practitioner (continued)
  • In the community
  • To participate in community and school
    activities
  • To utilize home visits
  • To work in professional organizations to promote
    prevention activities
  • To advocate with government officials on all
    levels to change laws/policies
  • To promote Healthy People 2010 objectives.

63
Designing Effective Prevention Programs
  • Promote protective factors
  • Reduce risk factors
  • Consider theories of behavioral change
  • Include strategies that enhance client-provider
    interaction and participation
  • Consider cultural factors

64
Theories of Change
  • Social cognitive theory (Bandura, 1986)
  • Problem-based theory (Jessor Jessor, 1997)
  • Peer cluster theory (Oetting Beauvois, 1986)
  • Theory of ethnic identity (Phinney, 1990)
  • Transtheoretical model (Prochaska DiClemente.
    1983)

65
Cultural Competence
  • Link between cultural competence and success or
    failure of preventive interventions
  • Successful programs take into account dominant
    and non-dominant cultures n which individuals
    live
  • Growing body of literature to guide the
    practitioner/researcher in developing cultural
    competence programs

66
General Prevention Strategies
  • Information dissemination
  • Development of life-coping skills
  • Provision of alternatives
  • Community development
  • Advocacy for a healthy environment
  • Problem identification
  • (CSAP, 1999)

67
Elements of Effective Programs
  • Standardized training materials
  • Social learning theory methods
  • Periodic booster sessions
  • Techniques to extend program beyond the setting.
  • (Pentz, 1999)

68
Combined Strategies in Communities are Most
Effective
  • Curriculum in schools
  • Parent involvement
  • Support by community leaders and health
    professionals
  • Enforcement of policies
  • Use of mass media to enforce messages
  • (Pentz, 1999)

69
Settings for Community-Based Strategies
  • Schools
  • Religious organizations
  • Community centers
  • Youth organizations
  • Family centers
  • Senior centers
  • Libraries and other community facilities

70
Community-Based Participatory Approaches
  • Participatory Action research
  • Community-based participatory research
  • Action research

71
Community-Based Participatory Approaches
(continued)
  • Assure that programs are tailored to community
  • Increase community capacity to deliver
    interventions
  • Result in increased knowledge and social change
  • Involve interactions between researcher and
    stakeholders

72
Evaluation Rationale
  • A systematic way to monitor clients outcomes
    that result from intervention.
  • Feedback that reflects the need to make
    adjustments.
  • Evidence that the program works and is cost
    effective.
  • Findings that contribute to the development of
    best practices in prevention efforts.
  • A method to disseminate findings to others in the
    field. (Prevention Programs for Youth, 1998)

73
Evaluation
  • Process
  • Documenting all aspects of implementation of the
    program
  • Outcomes
  • Short-term benefits new knowledge, improved
    skills and changed attitudes
  • Long-term benefits changed behaviors, reduced
    risks and enhanced protective factors.

74
The Getting to Outcomes Framework
75
Summary
  • Community-based substance abuse prevention
  • Complex, multifaceted process
  • Domain of health care professionals
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