This is the second Prevention Nugget to address Building Prevention Systems. As indicated before, there are four Prevention Nuggets on this topic addressing: Consumers of Prevention Services, the Services Delivered, and the Prevention Professionals who implement and monitor these services, and the Service Delivery System.
What could a Prevention Service Delivery System Look Like?
To review, the key elements of the system are the consumers who may not seek prevention services; the services that are delivered that may or not be evidence-based, the prevention professionals who deliver the services who vary not only in their training but also may not be certified as prevention professionals, and the service delivery system that that may be prevention focused, for example community coalitions, schools, county boards, and in some case law enforcement there is generally no prevention structure that is identifiable. Furthermore, funding for prevention services is primarily from public funding, often federal or State, or from foundations and is not based on documented need (as we say in the Prevention Nugget on Consumers of Prevention Services).
An earlier Prevention Nugget focused on The Etiology Model (October 5, 2020). The term etiology is the study to determine specific factors that cause or are related to a health or behavioral outcome, and the factors which produce or predispose toward a certain disease or disorder. For a problem behavior such as substance use, there is no one clear factor or set of factors involved; in general, it is an interactive process between an individual and his or her micro- and macro-level environments. The Etiology Model also identifies opportunities to intervene with prevention interventions. Let’s look at the components of the process:
• Personal Characteristics. When we are born, we have our own biological and physiological characteristics that make us unique. These shape how we behave and interact with our environments. Positive environments support us in our development; negative environments can interfere with development and make us vulnerable. Prevention interventions support positive development and also intervene effectively to help those at risk
• Environmental Influences. We are also born into both micro- and macro-level environments, which can play a role in the initiation and continuation of Psychoactive Substance Use. The micro-level environments are the influencers that are immediate or most proximal to us such as our schools and families. School-based interventions help youth develop important life skills and positive decision-making for their health and well-being. The macro-level environments are the larger neighborhood, community, and society. Again, macro-level prevention programming builds prosocial norms that protect against negative influences on youth such as advertising that promote underage smoking and alcohol use.
The interactions between and across these environments can be positive and result in our development and growth into productive adults, but they can also be negative and result in stresses and possibly our engagement in potentially harmful behaviors or lifestyles. It is important to emphasize that this process takes place across the lifespan as we interact with different micro- and macro-level environments.
Implementing Evidence-Based Prevention Interventions and Policies
Prevention professionals need to work with their communities to assure that those who need help get the assistance they need either through helping key socialization agents such as parents, teachers, sports coaches, even supervisors in the workplace or through direct service delivery including enforcing environmental regulations and policies regarding access to and availability of alcohol, tobacco, cannabis, and psychoactive medications. For this reason, an array of evidence-based prevention services are needed in any community. Examples of evidence-based family/parenting programs include:
Incredible Years is designed to prevent and treat young children’s behavior problems and promotes their social, emotional and academic competence. (https://incredibleyears.com/)
Triple P (Positive Parenting Program) is designed that affects multiple outcomes and reduces risk for SUDs. (https://www.triplep-parenting.com/nc-en/triple-p/)
Strengthening Families Program and its adapted version for Black Families, SAAF. Evidence-based family skills training program for high-risk and general population families, specifically showing reductions in SUD and useful for parents with SUD and their children. (https://strengtheningfamiliesprogram.org/).
Examples of evidence-based school programs include:
Good Behavior Game is a classroom behavior management strategy designed for early grades to help children master their role as students and to succeed in school. https://goodbehaviorgame.air.org/
Life Skills Training targeting middle and high school students has been shown to reduce substance use and violence through cognitive-behavioral skills that enhance decision-making, problem solving, critical thinking, and communications skills. (https://www.lifeskillstraining.com/)
Project Toward No Drug Abuse (https://tnd.usc.edu/) is a prevention program for high school youth who are at risk for substance use and violence-related behavior that provides instruction in motivation activities to not use drugs; skills in self-control, communication, and resource acquisition; and decision-making strategies
An example of a prevention program that cuts across home, school, and community is Multisystemic Therapy the provides caregivers the tools they need to transform the lives of troubled youth. Research demonstrates that MST reduces criminal activity and other undesirable behavior. (https://www.mstservices.com/).
Having evidence-based prevention services across the spectrum from universal, selected to indicated programs assures that the needs of consumers in any community will be addressed. And having in place efforts to assure that environmental policies are enforced help support community norms and expectations reflecting no substance use among minors, appropriate moderate use of licit substances among adults, and only medically monitored psychoactive medications among those who need such medications for health conditions. Finally, having evidence-based media support for these programs reinforces their availability and validity.
Building a Community-Based Implementation System to Support a Comprehensive Prevention Service Delivery System
However, to organize, implement and monitor such a range of services requires a central infrastructure. Such a structure assures that the services are delivered to the appropriate consumers, are delivered with fidelity, and meet short-, intermediate-, and long-term outcomes.
We have long recognized the importance of involving the community in identifying needs and required services to address these needs. Communities were involved in preventing the spread of infectious diseases going back to the Black Plague, although the causes of these diseases were not known at that time. Integrating community elements has been the foundation of public health for a very long time particularly with the recognition that individual behaviors were not enough to address the health of the community. Many efforts have been made around the world to involve the community in some way to address health needs. Good examples of these efforts in the U.S. are the Stanford Three Community Study conducted by Stanford University from 1979 through 1990 and the Midwestern Prevention Project conducted by the University of Southern California during the 1980s.
The Stanford Three Community Study used a community education campaign to address cardiovascular disease through changing dietary practices and reducing smoking among the general population. The Midwestern Prevention Project addressed substance use in Kansas City, Missouri using mass media programming, a school-based educational program, parent education programs, community organization that included business leaders, and health policy components that are introduced sequentially into communities during a 6-year period. These studies showed how multiple interventions within a defined geographic area could have an impact on health-related behaviors.
Based on this history, in the late 1990s the Center for Substance Abuse Prevention funded the community partnerships, and the Robert Wood Johnson Foundation funded the Fighting Back Community Coalitions. Evaluations of these two coalition efforts found that both failed to bring about changes in youth AOD use. WHY?
The evaluations indicated that the coalitions involved in these projects had insufficient guidance as to how to enact prevention strategies, varied widely in the nature and amount of prevention services provided, and largely relied on locally created prevention strategies that had not been previously evaluated for effectiveness in reducing AOD use. These studies suggest that the mere presence of an active, well-intentioned coalition is not enough to prevent AOD use. In other words, simply gathering local stakeholders and asking them to collaborate to do their best to solve local substance use problems does not produce desired changes. A coalition is not an intervention but is a structure developed to guide, support, and sustain effective prevention interventions and policies.
Instead, the evidence suggests that in order to be successful, coalitions must ensure:
They have clearly defined, focused, and manageable goals;
They have adequate planning time;
Prevention decisions must be based on empirical data about what needs to change in the community and on evidence from scientifically valid studies of what has worked to address those needs.
They must implement prevention policies, practices, and programs that have been tested and shown to be effective; and they must carefully monitor prevention activities to ensure implementation quality and fidelity.
Each community varies in terms of its human, service, and funding resources; coalition structures will vary across communities and may change over time. The coalition model should build on the competencies and leadership abilities that exist within the communities. Coalition structure is important and should include clear guidelines on leadership, decision-making, membership roles and fiscal responsibilities along with on-going assessments to determine gaps in knowledge and expertise of coalition members along with training to address these gaps. Finally, not all communities are ready to form a coalition or partnership.
Example of such infrastructures that have been shown to be effective in supporting a range of prevention services are community partnerships or coalitions. Two such programs include:
Promoting School-Community-University Partnerships to Enhance Resiliency (PROSPER) is based on a multi-tiered structure consisting of (a) community teams, (b) a stare-level management team, (c) a prevention coordinating team and (d) a national level tier. Key to the PROSPER structure is the Cooperative Extension System at Land Grant University and the public school system. PROSPER combines Strengthening Families Program: For Parents and Youth 10-14 and LifeSkills Training and targets families with middle-school children. PROSPER has shown to reduce delinquency and substance use during high school and promote family management practice and parent-child affective quality (https://helpingkidsprosper.org/)
Communities that Care (CTC). CTC is designed to reduce levels of adolescent delinquency via the selection of effective prevention programs tailored to a community's specific risk and protection profile based on survey data. Through training events and community activities, CTC aims to produce community-level changes in the service system characteristics, including increased collaboration among providers and feature adoption od evidence-based programs that address the risk and protective factors the community priorities. In turn, reductions in community risk factors reduce adolescent delinquent behaviors (https://youth.gov/content/communities-care).
References
Drug Strategies. (2001). Assessing Community Coalitions. www.drugstrategies.org
Fagan, A.A., Hawkins, J.D., & Catalano, R.F. (2011). Engaging Communities to Prevent Underage Drinking. Alcohol Research & Health, 34(2), 167-174.
Fortmann, S.F., Taylor, C.B., Flora, J.A., & Jatulis, D.E. (1993). Changes in Adult Cigarette Smoking Prevalence After 5 Years of Community Health Education: The Stanford Five-City Project. American Journal of Epidemiology, 137(1): 82-96.
Hallfors, D., Cho, H., Livert, D., & Kadushin, C. (2002). Fighting back against substance abuse: Are community coalitions winning? American Journal of Preventive Medicine, (23)4, 237-245.
Pentz, M.A., Dwyer, J.H., MacKinnon, D.P., Flay, B.R., Hansen, W.B., Wang, E.Y.I., & Johnson, C.A.. (1989). A Multicommunity Trial for Primary Prevention of Adolescent Drug Abuse Effects on Drug Use Prevalence. Journal of the American Medical Association, 261(22):3259-3266.
Yin, R.K., Kaftarian, S.J., Yu, P., & Jansen, M.A. (1997). Outcomes from CSAP's community partnership program: Findings from the national cross-site evaluation, Evaluation and Program Planning, (20)3, 345-355.