Promoting science-based prevention in communities

Transcription

1 Addictive Behaviors 27 (2002) Promoting science-based prevention in communities J. David Hawkins*, Richard F. Catalano, Michael W. Arthur Social Development Research Group, University of Washington, rd Avenue NE, Suite 401, Seattle, WA 98115, USA Abstract In the past decade, prevention science has emerged as a discipline built on the integration of life course development research, community epidemiology, and preventive intervention trials [Am. Psychol. 48 (1993) 1013; Am. J. Community Psychol. 27 (1999) 463; Kellam, S. G., & Rebok, G. W. (1992). Building developmental and etiological theory through epidemiologically based preventive intervention trials. In J. McCord & R. E. Tremblay (Eds.), Preventing antisocial behavior: interventions from birth through adolescence (pp ). New York: Guilford Press.]. Prevention science is based on the premise that empirically verifiable precursors (risk and protective factors) predict the likelihood of undesired health outcomes including substance abuse and dependence. Prevention science postulates that negative health outcomes like alcohol abuse and dependence can be prevented by reducing or eliminating risk factors and enhancing protective factors in individuals and their environments during the course of development. A growing number of interventions have been found to be effective in preventing adolescent tobacco, alcohol, and other drug abuse, delinquency, violence, and related health risk behaviors by reducing risk and enhancing protection. During the same decade, comprehensive community-based interventions to prevent adolescent health and behavior problems have been widely implemented in the U.S. with federal and foundation support. Despite the advances in the science base for effective preventive interventions and the investments in communitywide preventive interventions, many communities continue to invest in prevention strategies with limited evidence of effectiveness [Am. J. Public Health 84 (1994) 1394; J. Res. Crime Delinq. 39 (2002) 3; J. Community Psychol. 28 (2000) 237; J. Community Psychol. 28 (2000) 237; J. Consult. Clin. Psychol. 67 (1999) 590; Eval. Program Plann. 20 (1997) 367.]. Translating prevention science into community prevention systems has emerged as a priority for prevention research [J. Community Psychol. 28 (2000) 363; J. Appl. Behav. Anal. 28 (1995) 479.]. The Communities That Care (CTC) prevention operating system is a field-tested strategy for activating communities to use prevention science to plan and implement community prevention systems. CTC provides tools that assist * Corresponding author. Tel.: ; fax: address: jdh@u.washington.edu (J.D. Hawkins) /02/$ see front matter D 2002 Elsevier Science Ltd. All rights reserved. PII: S (02)

2 952 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) communities to use local data on risk and protective factors to identify elevated risks and depressed protective factors in geographic areas where levels of risk are high and levels of protection are low and then to implement tested, effective preventive interventions that reduce the identified risks and enhance protection in these [Developmental Research and Programs. (1997). Communities That Care: a comprehensive prevention program. Seattle, WA: Author; Developmental Research and Programs. (2000a). Communities That Care: a comprehensive prevention program. Seattle: Author; Hawkins, J. D., Catalano, R. F., et al. (1992). Communities That Care: action for drug abuse prevention (1st ed.). A joint publication of the Jossey-Bass social and behavioral science series and the Jossey-Bass education series. San Francisco: Jossey-Bass]. The CTC system is widely implemented, and process evaluations of CTC suggest that it can assist communities to develop more effective prevention systems. This paper describes the background and use of the CTC operating system and results of evaluations of implementation of the system. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Community; Prevention; Drug abuse; Alcohol abuse; Communities That Care; Risk and protective factors; Tested effective programs 1. Background and context The public health model for prevention of disease and disorder involves assessing the epidemiology of a targeted problem, identifying risk factors associated with the problem, applying interventions known to reduce these risk factors and enhance protective factors that buffer against the effects of risk, and monitoring the impact of these interventions on the incidence and prevalence of the targeted disease or disorder. This model for prevention has been used to prevent diseases such as malaria and cholera (Last, 1988), as well as to prevent behavioral disorders such as violence, alcohol abuse, and suicide (Mercy, Rosenberg, Powell, Broome, & Roper, 1993; Mrazek & Haggerty, 1994). To focus attention on the most pressing public health concerns, the Centers for Disease Control and Prevention has identified six preventable behaviors, usually initiated in childhood and adolescence, that contribute substantially to the most serious health problems, as well as associated educational and social problems, among residents of the United States. These six behaviors include alcohol and other drug use, risky sexual behaviors, tobacco use, behaviors that result in unintentional and intentional injuries, unhealthy dietary patterns, and physical inactivity (CDC National Center for Chronic Disease Prevention and Health Promotion, 2002). Research on the epidemiology of these behaviors indicates that they frequently cooccur among adolescents (Cohen & Potter, 1999; Duncan, Strycker, & Duncan, 1999; Everett, Giovino, Warren, Crossett, & Kann, 1998; Everett, Malarcher, Sharp, Husten, & Giovino, 2000; Hicks, Bemis Batzer, Bemis Batzer, & Imai, 1993; Huizinga & Jakob-Chien, 1998; Kingery, Pruitt, & Hurley, 1992). Precursors of these preventable behaviors, in individuals and their environments, include risk factors that predict an increased likelihood of problems and protective factors that mediate or moderate exposure to risk in predicting decreased likelihood of abuse or

3 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) dependence. Reviews of prevention research indicate that risk and protective factors should be primary targets for preventive intervention, and that a risk reduction/protection enhancement model is the best available framework for the prevention of adolescent health and behavior problems (CDC, 1994; Coie et al., 1993; Durlak, 1998; Hawkins, Arthur, & Catalano, 1995; Howell & Hawkins, 1998; Mrazek & Haggerty, 1994; National Research Council Institute of Medicine et al., 1996; Sloboda & David, 1997; Weissberg & Greenberg, 1997). Research has identified a variety of risk and protective factors for adolescent substance use (Bry, McKeon, & Pandina, 1982; Hawkins, Catalano, & Miller, 1992; Kandel, Simcha Fagan, & Davies, 1986; Newcomb & Felix Ortiz, 1992). Risk and protective factors have been identified in the domains of community, family, school, and peer group, and within individuals. As shown in Table 1, many of the risk factors for adolescent substance abuse also predict delinquency, violence, risky sexual behaviors, school misbehavior, and dropping out of school (Cairns, Cairns, & Neckerman, 1989; Coie et al., 1993; Dryfoos, 1990; Guo et al., in press; Hawkins, 1999; Herrenkohl et al., in preparation; Howell & Hawkins, 1998; Howell, Krisberg, Hawkins, & Wilson, 1995; Lonczak et al., 2001; Yoshikawa, 1994). Further, the likelihood of health and behavior problems is substantially greater among those exposed to multiple risk factors during development (Bry et al., 1982; Mrazek & Haggerty, 1994; Newcomb, Maddahian, & Bentler, 1986; Pollard, Hawkins, & Arthur, 1999). These findings suggest that interventions that reduce multiple risk factors in individuals and their socializing environments hold promise for preventing multiple adolescent health and behavior problems including tobacco and other substance abuse, risky sexual behavior, violence, delinquency, and school dropout. Experimental evaluations of risk- and protection-focused preventive interventions have documented reductions in risk and increases in protection, as well as reductions in substance abuse, delinquency, and violence (for reviews, see Brewer, Hawkins, Catalano, & Neckerman, 1995; Catalano, Berglund, Ryan, Lonczak, & Hawkins, 1999; Durlak, 1998; Hansen, 1992; Hawkins, Arthur, & Olson, 1997; Mrazek & Haggerty, 1994; Tobler et al., 2000; Yoshikawa, 1994). For example, school programs that teach social competencies and establish norms against tobacco and other substance use have reduced favorable attitudes towards substance use and the prevalence of alcohol, tobacco, and other drug use in school populations (Botvin, Schinke, Epstein, Diaz, & Botvin, 1995; Ellickson & Bell, 1990; Hansen & Graham, 1991; Pentz et al., 1989; Sussman, Dent, Stacy, & Craig, 1998). School programs focused on improving academic performance and bonding to school and family, and reducing antisocial behavior have produced reductions in early aggressiveness (Hawkins, Von Cleve, & Catalano, 1991; Tremblay et al., 1992), improvements in parent and school bonding and academic performance, reductions in early substance use (Hawkins, Catalano, Morrison, et al., 1992; O Donnell, Hawkins, Catalano, Abbott, & Day, 1995) and long-term reductions in violent behavior, risky sexual behavior, and heavy alcohol use (Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999; Lonczak, Abbott, Hawkins, Kosterman, & Catalano, 2002). Community-wide policy changes to reduce availability of tobacco to young people have resulted in decreased cigarette smoking among youths (Forster et al., 1998; Jason, Berk, Schnopp Wyatt, & Talbot, 1999; Rigotti et al., 1997). Similarly, communitywide policy changes to reduce availability of alcohol to youths including increasing the

4 954 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) Table 1 Adolescent problem behaviors Risk factors Substance abuse Delinquency Teen pregnancy School drop-out Community Availability of drugs B B Availability of firearms B B Community laws and norms B B B favorable toward drug use, firearms, and crime Media portrayals of violence B Transitions and mobility B B B Low neighborhood attachment B B B and community disorganization Extreme economic deprivation B B B B B Family Family history of the B B B B B problem behavior Family management problems B B B B B Family conflict B B B B B Favorable parental attitudes and involvement in the problem behavior B B B School Early and persistent antisocial behavior B B B B B Academic failure beginning in B B B B B late elementary school Lack of commitment to school B B B B B Individual/peer Alienation and rebelliousness B B B Friends who engage in the B B B B B problem behavior Favorable attitudes toward B B B B the problem behavior Early initiation of the B B B B B problem behavior Constitutional factors B B B Used with permission from Channing Bete. Violence drinking age(cook& Tauchen, 1984; Joksch, 1988) and restricting how alcohol is sold(hingson, Strunin, Berlin, & Heeren, 1990; Holder & Blose, 1987) have decreased consumption and the frequency of alcohol-related traffic accidents and fatalities. Many of the effective substance abuse prevention interventions have focused on preventing or delaying the initiation of alcohol or other drug use during early adolescence because early initiation of use has been shown to increase risk for substance abuse and dependence

5 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) (Centers for Disease Control and Prevention, 1994; Everett et al., 1999; Grant & Dawson, 1997; Griffin, Botvin, Doyle, Diaz, & Epstein, 1999; Griffin, Botvin, Epstein, Doyle, & Diaz, 2000; Hawkins, Graham et al., 1997, 1999; Robins & Przybeck, 1985; Wagenaar et al., 2000). Studies of these interventions have demonstrated virtually immediate effects in preventing early initiation, and some have shown more prolonged effects in preventing the use and abuse of substances, high risk sexual behavior, and other health risk behaviors later in adolescence (Botvin et al., 1995; Chou et al., 1998; Hawkins et al., 1999; Lonczak et al., 2002; Park et al., 2000; Spoth, Reyes, Redmond, & Shin, 1999). These results indicate that focusing on preventing the initiation of alcohol and other drug use during early adolescence by addressing risk and protective factors salient during this development period is a viable approach for preventing later alcohol and other drug abuse and dependence. Despite the advances in the development of effective prevention strategies, the prevalence of substance use among young people in the U.S. remains high (Johnston, O Malley, & Bachman, 2002). In order to reduce the prevalence of substance abuse, methods for taking effective prevention policies and programs to scale in communities are needed. Because of limited resources for such widespread implementation, it becomes imperative to use methods for focusing effective strategies to address the most pressing needs of local populations (Schinke, Cole, Diaz, & Botvin, 1997). Going to scale requires effective mobilization of various sectors of communities to support widespread implementation of effective prevention strategies. Effective targeting of proven prevention strategies requires methods for assessing and prioritizing specific risk and protective factors in local community areas and matching effective interventions to these priorities (Arthur & Blitz, 2000; Botvin et al., 1995; Hyndman et al., 1992). The fact that risk and protective factors predictive of adolescent substance abuse exist in multiple ecological domains (community, school, family, peer groups) suggests that effective prevention should involve a comprehensive approach to identifying the factors of greatest relevance in a community, and selecting and implementing appropriate evidence-based responses to those priority factors. Research has suggested that community-wide risk reduction is a promising prevention strategy (Mrazek & Haggerty, 1994). Interventions targeting risk and protective factors at multiple levels within communities have been evaluated. For example, the Midwestern Prevention Project (Chou et al., 1998; Pentz et al., 1989) combined individual skills training for students, parenting skills training, school policy and curriculum changes, and communitywide norm and policy change interventions to address risk and protective factors in multiple domains. Similarly, Project Northland combined parent involvement/education programs, behavioral curricula, peer participation, and community task force activities to change community, family, and peer group norms and prevent adolescent alcohol use (Perry et al., 1993; Wagenaar & Perry, 1994). Communities Mobilizing for Change on Alcohol (CMCA) focused on mobilizing the community to change norms and youth access to alcohol through policy change and collaboration (Wagenaar et al., 2000). Findings from these communitylevel field trials provide evidence that community-wide risk reduction interventions can prevent alcohol and tobacco use among adolescents (Biglan et al., 1996; Biglan & Taylor, 2000; Perry, Williams, Komro, & Veblen-Mortenson, 2000; Perry et al., 1996; Wagenaar et

6 956 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) al., 2000). However, some of these studies were limited by small samples of communities or nonexperimental designs, and most reported small effect sizes on substance use outcomes. None of these community-wide interventions used the CTC approach of providing diagnostic tools for assessing risk and protection and matching prioritized factors with effective interventions. The success of investigator-initiated prevention trials has spurred a growing interest in community-based approaches to preventing community health problems and promoting community health (Israel, Schulz, Parker, & Becker, 1998; Lasker, 2000; Minkler, 1999; Wandersman et al., 1998). During the past decade, comprehensive community-based interventions to prevent adolescent health and behavior problems have been widely implemented in the U.S. with federal and foundation support from initiatives such as the Center for Disease Control and Prevention s Prevention Resource Centers, the Center for Substance Abuse s Community Partnership Demonstration Program, Title V of the Juvenile Justice Act of 1993, Robert Wood Johnson Foundation s Fighting Back, Healthy Nations, and Free to Grow initiatives, the National Cancer Institute s Project ASSIST, the Office of National Drug Control Policy s congressionally mandated Drug Free Communities program implemented through the Office of Juvenile Justice and Delinquency Prevention (OJJDP), Annie E. Casey Foundation s Rebuilding Communities initiative, and the Center for Mental Health Services Safe Schools, Healthy Students program. Despite the advances in the science base for effective preventive interventions and the investments in community-wide preventive interventions, many communities continue to invest in prevention strategies with limited evidence of effectiveness (Ennett, Tobler, Ringwalt, & Flewelling, 1994; Gottfredson & Gottfredson, 2002; Kaftarian & Wandersman, 2000; Lynam et al., 1999; Morrissey et al., 1997). Community health collaborations increasingly view health as physical and mental wellbeing, not simply the absence of disease. Community groups are learning that traditional health indicators such as morbidity and mortality data are not sufficient to measure the impact of their efforts, and that intermediate and community-relevant indicators are needed, such as behavioral and environmental health risks, social determinants of health such as poverty, employment and housing, as well as community assets and values (Green & Kreuter, 1999; Lasker, 2000). Studies of collaborative approaches to health improvement have documented variables associated with better partnership performance, as well as barriers or challenges to effective functioning (Israel et al., 1998; Lasker, 2000; Roussos & Fawcett, 2000). Factors that appear to facilitate effective collaborations are effective leadership, paid support staff, sound procedures and organizational structure, environment of trust, flexible funding, mutual benefit from participating in the collaboration, mechanisms for handling disagreements and conflict, clear mission, action planning process and documents, systematic documentation and feedback, appropriate technical assistance and support, and adequate time for community involvement in the process (Macaulay et al., 1999). Yet, community health collaborations often lack tools and training that could help them involve the full diversity of their community, track their success in building widespread collaboration, define measurable objectives, and assess progress toward their goals of improving the health of the community (Lasker, 2000).

7 2. The intervention J.D. Hawkins et al. / Addictive Behaviors 27 (2002) Communities That Care (CTC) is an operating system for prevention that addresses many of these needs. Communities are empowered to use data on community levels of risk and protection as diagnostic information to guide the selection of preventive interventions that address the community s profile (Arthur & Hawkins, in press; Developmental Research and Programs, 1994, 1997, 2000a; Hawkins, 1999). CTC assists community members to collect data on risk and protective factors at the local level. Using these data, communities select prevention services focused on specific geographic areas displaying the highest risk. Within these targeted areas, the most prominent factors can be identified and prioritized for preventive action. Preventive interventions are then selected for implementation that have demonstrated effectiveness in addressing the prioritized factors. Implementation of this approach should rationalize the prevention planning process by basing decision making on local epidemiological data on risk, protection, and adolescent health outcomes, including substance use. It also should prevent alcohol and other drug abuse more effectively by applying interventions shown to affect the most elevated risk and/or protective factors in specific geographical areas. At the same time, the community is empowered to choose from a growing number of tested, effective preventive interventions that are suited to the community profile of risk, protection, and demographics. This should enhance community ownership and commitment to implementation of the preventive interventions selected. It is instructive to compare the prevention planning approach outlined above with the predominant methods of prevention planning and resource allocation in the U.S. Many states use a capitation-based formula to distribute prevention funds based on population (e.g., Arthur et al., 1996; Breer, McAuliffe, & Levine, 1996). This approach ignores local variations in prevalence of substance abuse (Ford, 1985; Simeone, Frank, & Aryan, 1993) and levels of risk or protection (Arthur & Blitz, 2000; Hawkins, 1999). Federal and state funding agencies have begun to recommend that local planners use practices that have been tested and shown to be effective (Howell et al., 1995; Kansas Department of Social and Rehabilitation Services/ Alcohol and Drug Abuse Services, 1996; Sloboda & David, 1997; Substance Abuse and Mental Health Services Administration (SAMHSA), 2001; U.S. Department of Health and Human Services, 2000; Western Regional Center for the Application of Prevention Technologies, 1999). However, most leave the selection of specific preventive interventions to local prevention planners who are given little guidance in how to measure and understand local needs or how to determine the types of prevention strategies that are likely to have greatest success in their communities (Breer et al., 1996; Hudson & Dubey, 1986). In contrast, CTC facilitates the creation of strategic plans tailored to each community s unique profile of risk and protection. CTC empowers communities to approach prevention analytically. It puts in place tools that communities can use continuously to monitor their progress. By periodically reevaluating community levels of priority risk and protective factors, the proximal outcomes of risk reduction and protection enhancement efforts can be determined, and needed adjustments in programming can be made. The community mobilization and training component of CTC is guided theoretically by the social development model (SDM) (Catalano & Hawkins, 1996; Hawkins & Weis, 1985).

8 958 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) The SDM is used to describe the processes that lead to the strengthening of social bonding among children and adults within the community and the explicit expression of healthy beliefs and clear standards for behavior across developmental periods. These are important protective factors that motivate healthy behavior both at the level of the developing child and at the community level. We briefly explain the theory here (see Catalano & Hawkins, 1996) and then discuss how the SDM enhances the design of the CTC community mobilization and training components. The SDM builds on social control theory (Hirschi, 1969) and social learning theory (Akers, 1977; Bandura, 1977). It posits that bonding to prosocial groups and individuals (Garmezy, 1985; Rutter, 1980; Werner, 1989) and clear norms against antisocial behavior (Elliott, Huizinga, & Menard, 1989; Moskowitz, 1989) are protective factors that inhibit the development of health risk behaviors. Bonding consists of attachment and commitment to family, school, community, and positive peers and belief in the shared values of these social units. People who are bonded to prosocial groups are unlikely to violate the norms for behavior of those groups. Clear norms, in turn, provide the behavioral guidelines for those who are bonded to the group. The SDM hypothesizes that bonding is created when people are provided opportunities to be involved or to make a contribution to the social unit, when they have the skills to take advantage of their opportunities to contribute, and when they are recognized for their contribution. Interventions that strengthen these processes of opportunities, skills, and recognition are likely to enhance bonding to positive social groups and the adoption of healthy beliefs and clear standards for behavior. The SDM is used in CTC in two ways. First, the use of a shared theory for promoting healthy youth development helps to increase communication among community members and organizations that may implement diverse prevention actions in a wide range of settings. The SDM provides a consistent model and shared language for implementing effective preventive interventions across socializing domains. Second, the SDM guides the community mobilization and training component of CTC. The goal is to create commitment and ownership among members from diverse community sectors. Local ownership is a vital component of successful community health promotion interventions (Haglund, Weisbrod, & Bracht, 1990; Holder & Reynolds, 1998; Watt & Rodmell, 1988). CTC seeks to build ownership by creating opportunities for all interested community members to learn about risk- and protection-focused prevention science as a solution to youth health and behavior problems and to create together a common vision for positive youth development based on prevention science. CTC develops skills for diverse community groups to work together to assess and prioritize risk and protection and match priorities with effective prevention strategies. Community members learn to develop strategic action plans to reduce prioritized risks in their communities and evaluate the impact of implementing their plans. The CTC process also provides benchmarks to mark progress towards objectives and suggests appropriate recognition activities to enhance reinforcement for CTC board members. Recognition for board members and the community is built into the process through public relations strategies publicizing the board s progress. We expect that, by increasing opportunities, skills, and recognition for community members to work together toward a common vision for healthy youth development, CTC strengthens board members

9 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) bonds to the board and the community and strengthens their commitment to implementing science-based, tested preventive interventions using epidemiological data on risk and protective factors to prioritize needs. Stronger bonds and commitment to science-based prevention should lead to greater collaboration among service providers and other community members, improved implementation quality, synergy among the preventive interventions used in the community, and sustainability of the community s prevention efforts. Successful implementation of CTC requires training and tools for community activation, risk and resource assessment, and strategic prevention planning to institutionalize risk- and protection-focused prevention. The CTC intervention is manualized and includes training events, technical assistance, and guides for community leaders and board members. In each country where CTC operates, a single designated organization provides the materials, training, and technical assistance to communities necessary to implement the CTC operating system. In the U.S., that organization is Channing Bete. In the UK, it is CTC-UK. In the Netherlands, it is Nederlands Instituut voor Zorg en Welzijn (NIZW), and in Australia, it is CTC. CTC is implemented through five phases designed to mobilize community leaders and a community board to plan and implement a set of tested interventions to reduce elevated risk factors and promote protective factors in the community. The five phases of CTC are described here. In Phase 1, community leaders who seek to prevent adolescent substance abuse or other related health and behavior problems and those who seek to promote positive youth development assess their community s readiness to use the CTC system. This involves defining the community that will be involved, identifying key stakeholders who should be engaged, recruiting a community leader to champion the process, assessing current conditions, activities, and initiatives already operating in the community, and assessing conditions that could inhibit successful implementation of the CTC system. For example, in communities where key stakeholders do not view the prevention of adolescent substance abuse as a priority, and in communities where key organizations like schools and city governments are unwilling to collaborate to achieve shared goals, there is little readiness for CTC. In such communities, building community readiness is necessary before installing the CTC system. This first phase of CTC allows CTC training and technical assistance activities to be tailored to each community s specific stage of readiness. Phase 2 introduces and involves the community in the CTC process. CTC and principles of prevention science are introduced to key stakeholders and the broader community. Key stakeholders commit to use the CTC system. The community develops a vision for its children, and an organizational structure is put in place to help the community move towards its vision. Phase 2 begins with a half day orientation for key community leaders (mayor, police chief, school superintendent, and business, faith, community, and media leaders) to risk- and protection-focused prevention and the community mobilization processes. Key community leaders are expected to shape opinion and direct resources to ensure that the policies and programs developed through the CTC process are fully implemented and institutionalized in Phase 5 of CTC (Finnegan & Ervin, 1989). They also are expected to hold the community

10 960 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) prevention board and staff accountable for planning and carrying out CTC. The orientation defines roles and responsibilities of the key leaders and those of the community prevention board to be appointed by the key leaders. If they choose to adopt the CTC system, the key leaders make a commitment to actively support its installation, to hold the community board accountable for carrying out the third and fourth phases of the CTC process, and to maintain the board s visibility within the community. Following the key leader orientation, the key leaders identify and invite about 30 community members to constitute a community prevention board. The community prevention board is the mechanism for carrying out the planning and implementation activities of CTC. Whether constituting a new board or using an existing coalition or board, key leaders seek to ensure that the board includes members who represent the diversity of the community and who can assist in the development of linkages to resources, organizations, and agencies that can support the board s prevention work. The boards include leaders and opinion shapers in their respective sectors, leaders of grassroots constituencies, and school and agency representatives involved in delivering programs and services to children, families, and neighborhoods. Community prevention board members attend a 2-day orientation, which provides an overview of the CTC intervention and information on risk and protective factors, the social development strategy, development of the board s vision for the future of the community s children, and strategies for developing and maintaining effective board organization. A paid CTC facilitator or coordinator is required to staff the board s day-today activities. An important task for CTC Boards is to become representative, visible, enduring, and responsive collaborations of community residents, formal and informal community leaders, and agency representatives. A task force dedicated to ensuring that the board is attentive to all groups within the community is an important part of the CTC board s organizational structure. This task force establishes contacts with leaders of various grassroots constituencies and groups within the community to solicit their involvement on the community board and to discuss their concerns. The task force also reviews board activities and products with these informal leaders to insure the appropriateness and acceptability of the boards actions to all segments of the community. Task force members also seek to provide the leadership, coordination, and incentive management to motivate board members to remain active (Parcel et al., 1989; Prestby, Wandersman, Florin, Rich, & Chavis, 1990). CTC s Phase 2 activities are designed to involve everyone from grassroots citizens to key leaders of the community in owning and operating the CTC system. The community board conducts community assessments in Phase 3 and uses the results to draft the community s strategic youth development and prevention plan in Phase 4. In Phase 3, the community board develops a data-based profile of community strengths and challenges. Community board members participate in a 2-day training on how to utilize epidemiological data on risk and protective factors. Board members learn to interpret survey and archival social indicator measures of risk and protection. Community-specific data on levels of risk factors, protective factors, adolescent substance use, and other health and behavior outcomes are collected. The CTC Youth Survey (Arthur, Hawkins, Pollard, Catalano, & Baglioni, in press; Pollard et al., 1999) and validated archival indicators of risk

11 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) and protection are used. Surveys and archival records that measure only drug use or crime or other youth health and behavior outcomes are not adequate for this purpose. Measures of risk and protective factors must be included in order to identify appropriate foci for action to prevent future substance abuse and related health and behavior problems in each community. The CTC Youth Survey is administered to representative samples or to all consenting community students in Grades 6, 8, 10, and 12. The survey provides 23 validated indicators of risk factors and 10 validated indicators of protective factors predictive of youth substance use (Arthur, Hawkins, et al., in press), while key archival records such as census information provide data on risk factors not easily collected from surveys of students like extreme economic deprivation. The result is a complete picture of what is promoting healthy behavior and what factors are contributing to risk for substance abuse and related health and behavior problems in the community. The board uses the data to identify neighborhoods where youths are exposed to high levels of overall risk and low levels of protection, and to identify those risk factors that are most elevated and those protective factors most depressed in these areas, as well as in the community at large. Objective profiles of risk provide a basis for developing consensus about community action priorities. First, the results of the assessment can be used to focus resources on neighborhoods where children and adolescents are being exposed to greatest risk as illustrated in Fig. 1, showing three neighborhoods in a California community where overall risk is highest. Secondly, the results are used to prioritize a subset of two to five risk factors that will be addressed in the board s strategic plan. As illustrated in Figs. 2 and 3, different Fig. 1. Total aggregated risk factors perspective.

12 962 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) Fig. 2. Risk factor profile neighborhood no. 3. neighborhoods and communities confront different profiles of risk. Preventive actions should be designed to address the specific risks that are elevated in the community or neighborhood of concern. The profiles of risk and protection also provide baseline data for subsequent assessments of the community s progress in changing levels and trends in risk factors targeted by the board s strategic plans. Following the profiling and prioritization of risk and protective factors affecting community youths, prevention board members attend a 1-day resource assessment training. The training provides methods for assessing the community s existing prevention resources. The goal of this assessment is to identify gaps in existing policies, programs, and services that address the community s prioritized neighborhoods and risk factors. Gaps can include the lack of availability of preventive programs and services in prioritized neighborhoods, the use of ineffective prevention programs or services, poorly implemented services, or poorly enforced policies. The community board conducts a resource assessment to facilitate the development of a strategic plan that will build on existing community resources, avoid duplication of effort, and fill gaps in existing policies and programs. During Phase 4, the CTC board uses the assessments and prioritization done in Phase 3 to develop its action plan. Using the baseline assessment data on current levels of risk and protection, the board defines clear, measurable, desired outcomes with respect to risk reduction, protection enhancement, and health and behavior problem reduction goals. The desired outcomes are expressed as changes in levels of prioritized risks and protective factors that will be accomplished by a specified time. Specifying outcomes helps to clarify the

13 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) Fig. 3. Risk factor profile neighborhood no. 2. policies, programs, and actions that will be needed to achieve them and establishes criteria for evaluating the success of the plan later. Having specified their risk reduction and protection enhancement outcome goals, board members attend a 2-day Effective Prevention Strategies training workshop that reviews tested policies, programs and actions that have been effective in reducing the community s prioritized risk factors and enhancing protective factors in adequately controlled trials. The board selects specific tested actions that have been effective in reducing the risk factors the board has prioritized. The community board selects policies and programs from a menu of tested preventive interventions included in Communities That Care Prevention Strategies: A Research Guide to What Works (Developmental Research and Programs, 2000b). Each of the interventions included in the guide has shown positive effects in reducing one or more risk factors, enhancing protective factors, and reducing drug use and/or related behavior outcomes in controlled experimental or quasiexperimental studies. The guide also indicates those programs for which training, technical assistance, and manuals are available to guide communities in installation. Table 2 shows tested effective policies, programs, and actions included in the CTC Prevention Strategies Guide that focus on children in Grades 4 through 8 for which training, technical assistance, and materials are available in the U.S. Because change efforts are more likely to produce observable effects when prioritized risk and protective factors are addressed consistently across multiple socialization domains

14 964 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) Table 2 Menu of effective interventions for Grades 4 8 Name of effective program (Grades 4 5) Name of effective program (Grades 6 8) Parent training Preparing for the Preparing for the Drug-Free Years Drug-Free Years The Incredible Years: Parent s, Adolescent Transitions Program Teacher s and Children s Videotape Series Strengthening Families Program Strengthening Families Program The Iowa Strengthening The Iowa Strengthening Families Program Families Program Strengthening Families Program: Strengthening Families Program: for Parents and Youth for Parents and Youth Multidimensional Therapy Multidimensional Family Therapy Brief Strategic Family Therapy Brief Strategic Family Therapy Functional Family Therapy Functional Family Therapy Creating Lasting Connections Creating Lasting Connections Organizational change in schools School Development Program Classroom organization, management, and instructional strategies The Good Behavior Game Continuous Progress Instruction Computer-Assisted Instruction Cooperative Learning Programs Tutoring Programs Reading Recovery The Program Development Evaluation (PDE) Method Behaviorally-Based Prevention Program Continuous Progress Instruction Computer-Assisted Instruction Cooperative Learning Programs Classroom curricula for social and emotional competence promotion Growing Healthy Growing Healthy Promoting Alternative Adolescent Alcohol Thinking Strategies (PATHS) Prevention Trial (AAPT) Peace Builders Life Skills Training (LST) Program Know Your Body Know Your Body The Children of Divorce Reconnecting Youth Program Intervention Program Project Alert Alcohol Misuse Prevention All Stars Multicomponent programs based in schools Midwestern Prevention Project/Project Star Success For All Child Development Project Midwestern Prevention Project/Project Star Project Northland

15 Table 2 (continued) Name of effective program (Grades 4 5) Name of effective program (Grades 6 8) Mentoring Big Brothers/Big Sisters J.D. Hawkins et al. / Addictive Behaviors 27 (2002) Big Brothers/Big Sisters Across Ages Community mobilization The Midwestern Prevention Project/Project Star Community/school policies Regulation of Availability Taxation Mandatory Sentencing Laws for Use of A Firearm during the Commission of a Felony Community Policing Strategies The Midwestern Prevention Project/Project Star Regulation of Availability Taxation Community Policing Strategies (Catalano, Haggerty, Fleming, Brewer, & Gainey, 2002; Tobler et al., 2000), community boards are encouraged to select preventive interventions for implementation that affect risk and protection in family, school, and community domains. By selecting interventions in each domain, it is hypothesized that the new interventions will have a synergistic impact on the prioritized risk factors. For example, an important goal of a community s strategy may be to strengthen norms against early initiation of alcohol use in all three domains, thus creating clear and consistent behavioral expectations for youths in the community. Using CTC, family-, school-, and youth-focused preventive actions are implemented in the context of a community where formal and informal leaders have joined to establish a shared vision for the future of the community s children, where this vision is repeatedly presented to the entire community, and where there is an ongoing invitation to community members to support and participate in the efforts to move toward this vision. Community action plans describe the evidence-based prevention strategies selected to address prioritized risk and protective factors and include work plans to implement these new strategies in the community. The plans describe how each selected intervention will be implemented to reach the community s youths living in neighborhoods where overall risk exposure is high with mutually reinforcing risk reduction and protection enhancement activities affecting family, school, and community. The plans also specify how the interventions will be coordinated with existing programs and resources. They also specify plans for monitoring implementation quality and providing feedback to support continuous quality improvement (Wandersman et al., 1998) and for assessment of progress towards specified process and outcome goals. In Phase 5, after finalization of the action plan and its approval by the community s key leaders, the CTC board implements and evaluates the plan. A task force of the board is created for each new intervention to be installed. Task force members include program implementers and members of their support structure. For example, the task force to oversee

16 966 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) implementation of a tested school curriculum for social competence promotion would include at least one CTC board member, teachers, a principal, a parent whose child attends the school where the program will be implemented, a school district representative, and possibly other school support staff. Task force members develop steps to achieve high quality program implementation and to implement process measures included in the action plans so that implementation can be monitored. The CTC board insures that training is secured to implement the evidence-based prevention strategies in the plan. Communities contract for the specific training events required to implement their selected interventions with the organizations that provide this training. Follow-up training and ongoing technical assistance also are available from the CTC training and technical assistance organizations (in each country) to develop the capacity within CTC communities to implement the chosen strategies effectively, including removing barriers to implementation, marshalling resources, and developing procedures to monitor the implementation of each element and outcomes (Chavis, Florin, & Felix, 1992; Florin, Mitchell, & Stevenson, 1993). CTC boards seek to monitor the implementation of the policies and programs they have specified in their action plans. A wide range of measures may be used such as pretests posttests of program participants, participant exit interviews, archival data such as school performance and school discipline referral information, or community data such as numbers of shops selling tobacco and alcohol products within a certain distance of school buildings. Throughout the CTC process, CTC Boards work with local media. Media connections are used to educate community members about risk and protective factors for adolescent problem behaviors; communicate clear norms and enforcement policies regarding tobacco, alcohol, and other drugs in the community; generate public support for the CTC process and prevention actions taken; and motivate community members to take part in efforts to reduce risk factors and promote protective processes in the community. Representatives of the local media are recruited to the board to provide expertise in these efforts. CTC provides a framework for local communities and government agencies to work together toward common goals, mobilizes local resources, and, where added resources are needed, allows government agencies and foundations to invest in locally developed plans with confidence that they provide tested effective policies and programs tailored to the needs of each community. 3. Results of existing evaluations of CTC Two important questions about CTC require evaluation. First, does the CTC operating system improve community planning and decision making? Second, does use of the CTC system affect targeted risk and protective factors, increase healthy behaviors and reduce health and behavior problems in young people? Both questions have been addressed in evaluation studies, though a randomized controlled trial of CTC remains to be conducted. CTC was initially field tested in 25 communities in Washington State. Community coalitions were trained to use the risk- and protection-focused approach to plan and

17 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) implement strategic prevention programs targeting prioritized risk and protective factors (Harachi Manger, Hawkins, Haggerty, & Catalano, 1992). Evaluation of this project showed that community leaders and residents would participate in the CTC trainings and adopt and use the risk- and protection-focused approach to prevention planning (Harachi Manger et al., 1992). The CTC strategy was next field tested in Oregon. This test showed that, using CTC, riskand protection-focused prevention could be implemented and maintained by communities over an extended period of time. Of 40 communities invited to participate, 35 completed CTC trainings. Twenty-eight community boards completed action plans within 1 year of initial orientation. Twenty-seven of the CTC communities implemented risk-focused prevention programs within 1 year after receiving training in the planning process, though they had received no special funding for implementation (Harachi, Ayers, Hawkins, & Catalano, 1996). Thirty-one community boards were still actively working to reduce risk and increase protection using the planning process 4 years later (Harachi, Ayers, Hawkins, & Catalano, 1996). As shown in Table 3, these communities were significantly more likely to select and implement tested effective prevention strategies than a comparison group of communities participating in a similar project in Washington State that used a different model of training in risk-focused prevention, called Together We Can (TWC). Seventy-two percent of the Oregon communities using CTC implemented tested effective prevention programs compared with 48% of the TWC communities (Arthur, Ayers, Graham, & Hawkins, in press). These evaluations of the CTC strategy show that, even with limited funding, communities will adopt the CTC process, participate in the sequence of training events, use the strategy to develop comprehensive community action plans targeting specific risk and protective factors with tested, effective preventive interventions, and implement the selected interventions. Two separate studies of CTC have shown that participation in CTC training is a robust predictor of community adoption of a research based approach to prevention planning (Arthur, Glaser, & Hawkins, submitted; Greenberg, Osgood, Babinskik, & Anderson, 1999). The CTC operating system was adopted by the federal OJJDP and used to guide OJJDP s Title V Delinquency Prevention Program from 1993 to CTC s utility in helping Title V communities improve planning and decision making was evaluated by the U.S. General Accounting Office (1996). The GAO reported that different communities adopted different Table 3 Comparing CTC and TWC prevention operating systems (Arthur, Ayers, et al., in press) CTC (%), n = 35 TWC (%), n =39 Completed an action plan specifying tested effective prevention strategies Completed an action plan with untested 11 9 prevention strategies Did not complete an action plan Implemented tested effective prevention activities Implemented untested prevention activities Did not implement prevention activities 11 3 n = number of communities.

18 968 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) prevention strategies to address their own profiles of resources and risks; that 78% of the communities they studied used multiple approaches to address multiple risk factors in three or more domains; and that 90% of Title V communities employed two or more evidence based programs. OJJDP reported results from an independent evaluation of Title V using CTC in its 1996 Report to Congress. In Title V communities using CTC, the study found improved interagency collaboration, reduced duplication of services, coordinated allocation of resources, increased leveraging of resources for prevention programming, targeting of prevention activities to priority risk and protective factors, increased use of research-based approaches with demonstrated effectiveness, and increased involvement of professionals, citizens, and youth in community prevention activities (OJJDP, 1996). In a separate evaluation of Title V communities in Iowa, Jenson, Hartman, Smith, Draayer, and Schurtz (1997) reported that CTC s risk- and protection-focused framework was effective in educating local citizens about youth problems, led communities to focus on taking effective action to prevent youth problem behaviors, enhanced interagency collaboration and involved citizens not traditionally Table 4 Selected behavior outcomes Location Behavioral outcome 1996 Report to Congress of OJJDP s Title V prevention initiative (OJJDP, 1996) Ames, IA improved cognitive skills East Prairie, MO improved parenting skills, family relations, community relations Montgomery county, MD 12% decrease in suspensions 30% decrease in school problems Nekoosa, WI decrease in student detentions, academic failure, truancy Lansing, MI decrease in fights, suspension increased feelings of safety at school Port Angeles, WA 65% decrease in weapons charges 45% decrease in burglary 29% decrease in drug offenses 27% decrease in assault charges 18% decrease in larceny Iowa evaluation (Jenson et al., 1997) City of Clinton Story county Muscatine county Woodrow Wilson School improvements in school behavior and performance decreases in antisocial behavior improvement in refusal skills improvement in parenting skills decreases in arrests decreases in suspension decreases in court adjudications

19 J.D. Hawkins et al. / Addictive Behaviors 27 (2002) involved in prevention activities, and helped different communities to adopt different prevention strategies to address their own profiles of resources and risks. An evaluation of Pennsylvania s CTC system conducted by Greenberg, Feinberg, Gomez, Riggs, and Osgood (2002) found that CTC training increased board members knowledge and understanding of the CTC operating system. In turn, board knowledge of the CTC model and fidelity of implementation of the CTC system predicted the longevity or sustainability of CTC community boards:... the resources that the state and communities put into training at the beginning of the CTC process pay dividends later in terms of sustaining CTC after funding ends (Greenberg et al., 2002). In addition to the observed effects on community prevention systems, changes in rates and levels of youth behavior problems following implementation of CTC have been evaluated using nonexperimental designs in studies reported by the OJJDP (1996) and Jenson et al. (1997). As shown in Table 4, both studies reported improvements in youth behavioral outcomes following implementation of CTC in Title V communities, though these were not controlled studies. While these studies provide evidence that CTC empowers communities to implement effective prevention strategies, the effectiveness of CTC preventing alcohol and other drug abuse has not been investigated in a randomized controlled trial. 4. Conclusion The CTC operating system is designed to increase the likelihood that communities will select evidence-based prevention strategies tailored to their profiles of risk and protection and the likelihood that the planned interventions will be fully implemented and integrated with the services and activities of existing organizations in intervention communities. Once installed, these tested interventions should produce reductions in elevated risk factors and enhancements in depressed protective factors, and, in turn, they should produce enduring reductions in the prevalence of adolescent tobacco, alcohol. and other substance abuse, delinquency, and violence. Currently, the CTC operating system is being used in 14 communities in England, Scotland, and Wales, in four communities in the Netherlands under collaborative funding from the Ministry of Justice and the Ministry of Health, Welfare, and Sport, and in three communities in Australia, as well as in several hundred communities in the U.S. It is important to conduct a randomized controlled trial of CTC to ascertain the effectiveness of this operating system in changing community levels of risk, protection, and youth drug abuse and related health and behavior problems (Farrington, 2000; Peterson, Hawkins, & Catalano, 1992). References Akers, R. L. (1977). Deviant behavior: a social learning approach. (2nd ed.). Belmont, CA: Wadsworth Publishing. Arthur, M. W., Ayers, C. D., Graham, K. A., & Hawkins, J. D. (in press). Mobilizing communities to reduce risks for drug abuse: a comparison of two strategies. In W. J. Bukoski, & Z. Sloboda (Eds.), Handbook of drug abuse theory, science and practice. New York: Plenum.

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