Education And Prevention

American adolescents increased their use of most illicit substances throughout the 1990s after a significant drop in the previous decade, and in 1999 Drug Czar Barry McCaffrey responded to the recent Monitoring the Future study by saying drug use "remains unacceptably high" (University of Michigan Institute for Social Research, 1999). Data on special populations such as infants, the homeless, the ELDERLY, and those with HIV/AIDS indicate increasing needs for prevention and education throughout the life span. COCAINE and HEROIN patients in emergency rooms have also increased since 1990 and the American Lung Association estimates that 430,700 Americans die each year from diseases directly related to smoking. Clearly, the use of ALCOHOL, TOBACCO, and other drugs—whether licit or illicit—by various age groups and special populations continues to be a problem in the United States.

The concept of prevention has evolved since the 1960s to become much broader, one that has shifted from a focus primarily on adolescents to a life-span perspective that includes all ages from the fetus through the elderly. Prevention services recognize all potentially addictive substances—including alcohol, tobacco, MARIJUANA, cocaine, OPIOIDS, INHALANTS, HALLUCINOGENS, and prescription and nonprescription (OVER-THE-COUNTER, OTC) medications. Linkages have been developed with several services to include PREVENTION, intervention, and TREATMENT. Prevention programs now emphasize comprehensive long-term systematic programming for individuals, peer groups, FAMILIES, and/or communities. Such programs utilize prevention concepts based on the positive results of controlled experiments and quasi-experimental studies. They contain a core of pro-social skills central to the prevention of substance abuse as well as other social problems—SUICIDE, unwanted pregnancies, and VIOLENCE.

CONTEMPORARY PRINCIPLES OF PREVENTION

Several authorities have analyzed prevention programs for substance abuse and have listed principles of effective prevention programs (Dryfoos, 1990; Falco, 1992; Hawkins et al., 1992; The U.S. General Accounting Office, 1992; and The Higher Education Center for Alcohol and Other Drug Prevention, 1999). The principles in this section emerged from this literature as well as other sources. This type of "lumping," of necessity, ignores many subtle points applicable to specific programs or to particular issues. Nonetheless, widespread agreement exists that these principles provide a foundation for planning effective, cost-effective, prevention programming.

1. Effective prevention programs provide for comprehensive, coordinated services to individuals and their families along a continuum of care.

Comprehensive prevention programming in a community includes services for all age groups, with multiple forms of programming for any age group. Comprehensive services are arrayed along a continuum to include education, prevention, intervention, and referral to treatment when necessary. Further, most people in high-risk substance-abuse environments need a variety of other services—health, nutrition, prenatal care—along with substance-abuse prevention services. All of these services need to be coordinated for maximum effect and efficiency. In any community, pregnant women, children, adolescents, workers and/or elderly, some are in need of intervention rather than prevention; a comprehensive strategy provides for intensive services as required.

Effective prevention programs also involve the families of the target populations, either as the focus of the service or as a tangent to a service array. Such programs include training in relationships and parenting skills, while reinforcing family awareness of the purposes and procedures of substance-abuse prevention programs. Bry, Conboy, and Bisgay (1986) reported reduced substance use and fewer problems in programs for youth that taught their parents needed parenting skills.

Student-assistance programs and EMPLOYEE-ASSISTANCE PROGRAMS (EAPs) have emerged to fill an important gap in the care continuum. Such programs identify those whose performance (academic or work) deteriorates, to assist them in obtaining the most appropriate help. They are considered by businesses to be beneficial (U.S. Department of Labor, 1991), and schools perceive them as essential to their total programming (Swisher et al., 1993).

2. Effective prevention programs are developmentally appropriate, culturally relevant, and sensitive to ethnic minority members, females, and persons in special circumstances (e.g. homeless persons).

They must also be developmentally appropriate and adjusted to the emotional and mental development of the individual or group. Too often prevention programs have attempted to provide a diluted version of a program to a younger age group without considering the developmental stage. Programs must be adapted to an individual's needs in the various transitions of our lives. Some programs, for the oldest members of a community, must be designed for their particular needs and frequent involvement with chronic illness (Garrity & Lawson, 1989).

Prevention programs are most effective when they are culturally relevant to the norms and assumptions of the various ethnic and minority groups. Role models and media materials must be culturally sensitive or they will be rejected by the audience either consciously or subconsciously. Several authorities have compiled examples of successful experiences that a variety of programs have had with participants from diverse racial and ethnic orientations (e.g., Resnick & Wojcicki, 1991; Marcus & Swisher, 1992). A recent novella aimed at Hispanic youths and their families received accolades for cultural sensitivity and scope, and reader responses suggested the work had some positive impact on Hispanic youth attitudes toward alcohol (Lalonde, Rabinowitz, Shefsky, & Washienko, 1997).

Those in special circumstances (e.g., the homeless) require different approaches in the effective delivery of prevention services. For example, reaching and engaging the homeless requires different strategies (Federal Task Force on Homelessness and Severe Mental Illness, 1992) and some researchers have been successful (reduced drug use) with prevention programming for the homeless (Botvin and Dusenbury, 1992).

3. Effective prevention programs use behavior change technology to equip people with life skills, knowledge of substance abuse, and awareness of the services available to them.

Equipping people with life skills includes decision making; coping; knowledge about the effects of alcohol, tobacco, and other drugs; awareness of services; and assertiveness/refusing. This cluster of skills also equips people with the ability to manage their immediate situations with the healthiest outcomes. Such strategies teach people to understand that they are engaging in risky behaviors and give them the skills to resist peer pressure and other influences, such as ADVERTISING. Recent studies have shown that alcohol advertising may increase consumption, while counter-advertising and bans decrease alcohol use to some degree (Saffer, 1997).

There is somewhat dated but nonetheless relevant literature of prevention technologies, such as Life Skills Training (e.g., Botvin & Tortu, 1988) or Normative Education (Hansen, 1990), which provide intensive instruction in a variety of competencies. Similarly, there are several comprehensive curricula offered sequentially from kindergarten through twelfth grade (Center for Health Promotion, 1990). Only two of these comprehensive school curricula have had positive outcomes based on experimental evaluations; these are the Here's Looking At You editions (Comprehensive Health Education Foundation, 1990) and Growing Healthy (e.g., Connell, Turner, & Mason, 1985). Growing Healthy is a comprehensive health curriculum that includes a limited focus on alcohol, tobacco, and other drugs, whereas Here's Looking at You: 2000 is an alcohol, tobacco, and other drug-use-prevention curriculum.

The results of a groundbreaking study were released in 1996, when the U.S. Department of Education published the results of a word association test called the Environmental Assessment Initiative (EAI). The EAI looks at the language people use and from that determines attitudes and beliefs about alcohol—indeed, the EAI study reported 80 percent accuracy in noting differences between users and nonusers regarding perceptions about drugs and alcohol (Katz, 1996). The study suggests increasing the influence of students who do not overindulge in alcohol as a way of improving campus life. Possible steps include offering numerous activities that do not involve alcohol, as well as developing strategies and rules that shed romanticized views of alcohol abuse.

Effective PREVENTION PROGRAMS must provide accurate information that there are risks associated with the use of various substances. This scientifically based information—highlighting the relationships between an abused substance and its consequences—has been an important component in changing behavior in all age groups (Johnston, Bachman & O'Malley, 1993).

4. Effective prevention programs emphasize the early identification of risks and resiliency factors and program accordingly.

Effective substance abuse prevention programs emphasize early identification and intervention to reach a substance abuser and his or her family as early as possible, even in preschool programs. Risk status assessment coupled with interventions have become standard in effective prevention programs (Lorion, Bussell, & Goldberg, 1991).

Some communities are expanding programs such as Drug Abuse Prevention Education (DARE) from elementary classrooms into the junior high schools as well, hoping to send youths a positive message early and often—and at an age when many children are first exposed to drugs and alcohol.

Research by Hawkins and Lishner (1985) lists risk factors for school-age youth. These risk factors are important to a total process in planning for prevention services.

  1. family history of alcoholism
  2. family history of antisocial behavior or criminality
  3. family management problems
  4. early antisocial behavior and hyperactivity
  5. parental drug use and positive attitudes toward use
  6. academic failure
  7. little commitment to school and education
  8. alienation, rebelliousness, and lack of social bonding to society
  9. antisocial behavior in early adolescence
  10. friends (peers) who use drugs
  11. favorable attitudes toward drug use
  12. early first use of drugs

Risk factors for other age groups need to be researched if prevention practitioners are to be maximally effective in addressing all populations in a given community. Efforts have also focused on developing resilience in people at high risk (North-east Regional Center for Drug-Free Schools and Communities, 1992).

5. Effective prevention programs operate in communities that establish positive norms through enforcement of clear policies.

Communities that establish positive norms regarding alcohol, tobacco, and other drug use have also been successful in delaying the onset of use. Such communities have changed their policies toward access to substances by children and adolescents, including the location of advertisements and beverage-serving establishments; they have also promoted positive lifestyles. Gerbner (1990) has underscored the importance of communities reducing their ambivalence about communicating about all substances, licit or illicit.

Prevention services and policy changes have reduced the regular use of alcohol, tobacco, and other drugs, and there has been a concurrent reduction in consequences—including reduced highway ACCIDENTS because of alcohol; improved general health because of tobacco prevention; and reduced criminal activity because of illicit substance abuse. A 1992 report from the Office of the Inspector General confirmed an almost total lack of enforcement efforts by state agencies to control cigarette access, despite numerous provisions in existing state laws. In a study of media programming targeted to specific audiences and combined with community follow up, significant differences in the use of alcohol, tobacco, and other drugs were found between experimental and control groups (Flay & Sobol, 1983).

Pentz and colleagues (1989) demonstrated the effectiveness of community immersion in prevention through a program that included policy changes, refusal-skill training for junior high students, parent training, and mass media coordination. In this program, community groups monitored the availability of alcohol, tobacco, and other drugs and, in turn facilitated enforcement of existing policies or implemented new policies where needed.

An example of an ambitious prevention initiative is The Higher Education Center for Alcohol and Other Drug Prevention, created by the U.S. Department of Education in 1993. Alarmed by a Harvard study that confirmed almost half of U.S. college students engaged in heavy episodes of drinking, The Center formed the Presidents Leadership Group in 1997. This collaboration marked the first time in a decade that a group of college and university leaders joined forces to review alcohol abuse and develop a plan of prevention.

The Group published a report in 1997 that asked university presidents to acknowledge three major facts: student alcohol abuse is a problem all institutions of higher education share; student substance abuse is a problem of the community as a whole, not simply the campus; and student drinking is a problem that will never completely go away. The Group then listed their thirteen Proposals for Effective Prevention, among them: college presidents should use every opportunity to speak out and write about alcohol and other drug prevention to reinforce it as a priority concern and to push for change; college presidents should work to ensure that all elements of the college community avoid providing mixed messages that might encourage alcohol and other drug abuse; college presidents should appoint a campus-wide task force; college presidents should offer new initiatives to help students become better integrated into the intellectual life of the school, change student norms away from alcohol and other drug abuse, and make it easier to identify students in trouble with substance abuse; and college presidents should take the lead in identifying ways to effect alcohol and other drug prevention through economic development in the community (The Higher Education Center for Alcohol and Other Drug Prevention, 1997).

In November, 1996, forty-nine college presidents in Ohio decided to address the problem of student binge drinking by signing a letter of commitment. Institutions soon formed action teams to develop prevention plans. Educators found that communities reacted positively to university commitment against alcohol abuse.

6. Effective prevention programs provide staff development and training.

Effective prevention programs provide training for staff at all levels. The behavior-change and the other intervention techniques require constant upgrading of staff skills, supervision, and feedback. New prevention and intervention techniques require intensive training for proper implementation. This specialized training should be available at colleges, universities, and vocational training centers. Moreover, there is a world of information on alcohol and drug abuse education available on the Internet, including home pages for DARE and The Higher Education Center for Alcohol and Other Drug Prevention, as well as dozens of support sites.

The results of the several controlled-outcome studies of teacher training have been summarized by Swisher and Ashby (1993). They concluded that for each negative result (e.g., increase in beer use) there were five positive findings (e.g., reduced use of various substances). The training involved a tenday retreat in which teams of teachers were given planning skills and prevention techniques. The planning skills led to an action plan to be implemented upon return to one's school; the prevention techniques were designed to be immediately implemented and reinforced with additional training sessions and technical assistance. Students in these schools have reported an improved school climate and improved academic functioning.

ENDURING MYTHS

Myths about prevention of substance abuse continue to impede progress toward more effective services. Some of the myths that need to be addressed as part of an advocacy for effective prevention principles include the following: (1) substance abuse cannot be prevented because it is caused by genetic and other biological phenomena; (2) there is no evidence that prevention works; and (3) scarce resources should be given to increasing availability of treatment for those in need.

Instead, most problems in this area are seen as being caused by the interaction of the biology, psychology, and social environment of the individual and the term that is emerging is biopsychosocial problems, indicating an interaction of these domains in social problems. There is clear evidence that genetic and other biological factors play a role in substance abuse, but more important is the social environment at all ages, which plays a significant role in increasing risk for the onset of a disorder. In some cases, it is possible to provide at-risk individuals with coping skills before a crisis occurs—to better enable them to avoid or manage the event (Institute of Medicine, 1989).

A large number of studies indicate that prevention works. For example, an issue of the Journal of Community Psychology (Lorion & Ross, 1992) included a series of articles that clearly demonstrated that prevention services for high-risk youth can reduce alcohol, tobacco, and other drug use as well as related social problems. The American Psychological Association published a well-documented listing of successful prevention programs (Price, Cowen, & Lorion, 1988). An outstanding longitudinal study was reported by Botvin (1993), in which he outlined a successful six-year follow-up of life-skills training.

CONCLUSION

Providing prevention services at any point along a continuum reduces demand while reducing costs for subsequent services. It also reduces related costs, such as accidents, illness, death, and crime. It is most cost effective to provide services as early as possible. However, budget priorities continue to emphasize law enforcement and treatment over prevention.

For prevention to play an appropriate role in responding to the problem of drug use and abuse, the federal, state, and local governments need to establish standards and ensure that the best practices in prevention and education are provided to all ages. The major obstacle remaining is the lack of means to train professionals and volunteers in what is known and to assist them in implementing the best practices. Unfortunately, most of the very limited government monies available for prevention of substance abuse are allocated to a flowthrough blockgrant mechanism or to the development of new models—without a follow-up system of disseminating or replicating what is already known about effective prevention.

(SEE ALSO: Adolescents and Drug Use; Disease Concept of Alcoholism and Drug Abuse; Families and Drug Use; Homelessness, Alcohol, and Other Drugs; Parents Movement; Partnership for a Drug-Free America; Prevention)

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JOHN D. SWISHER

ERIC GOPLERUD

REVISED BY MATTHEW MISKELLY