1 Health Promotion International Advance Access published February 2, 2014 Health Promotion International doi: /heapro/dau001 # The Author Published by Oxford University Press. All rights reserved. For Permissions, please Coalition formation to address structural determinants of methamphetamine use in Thailand NANCY WILLARD 1,2*, BANGORN SRIROJN 3, NICHOLAS THOMSON 4, APINUN ARAMRATTANA 3, SUSAN SHERMAN 4, NOYA GALAI 4, DAVID D. CELENTANO 4 and JONATHAN M. ELLEN 1 1 Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA 2 Johns Hopkins Bayview Medical Center, Mason F. Lord Building, Center Tower Suite 4200, 5200 Eastern Avenue, Baltimore, MD , USA 3 Research Institute for Health Sciences, Chiang Mai University, Chiang Mia, Thailand and 4 Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA *Corresponding author. SUMMARY Despite two recent government-sponsored wars on drugs, methamphetamine use continues to be a pervasive problem in Thailand. Out of concern for reported human rights abuses, there has been a call from the international community to take a different approach from the government s zero tolerance. This paper describes the adaptation of the Connect to Protectw coalition formation process from urban U.S. cities to three districts in northern Thailand s Chiang Mai province, aimed to reduce methamphetamine use by altering the risk environment. Project materials, including manuals and materials (e.g. key actor maps and research staff memos), were reviewed to describe partnering procedures and selection criteria. Potential community partners were identified from various government and community sectors with a focus on including s from health, police, district and sub-district government officials. Of the 64 potential partners approached, 59 agreed to join one of three district-level coalitions. Partner makeup included 25% from the health sector, 22% who were sub-district government officials and 10% were s from the police sector. Key partners necessary for endorsement of and commitment to the coalition work included district-level governors, police chiefs and hospital directors for each district. Initial coalition strategic planning has resulted in policies and programs to address school retention, youth development initiatives and establishment of a new drug treatment and rehabilitation clinic in addition to other developing interventions. Similarities in building coalitions, such as the need to strategically develop buy-in with key constituencies, as well as differences of whom and how partners were identified are explored. Key words: structural change; risk environment; coalitions; community development INTRODUCTION Methamphetamine (MA) use has been a persistent and pervasive problem in Thailand since the mid-1990s and has risen to epidemic proportions, as it continues to be trafficked from Burma and other bordering countries through Thailand for worldwide distribution (United Nations Office on Drugs and Crime [UNODC], 2003; UNODC, 2008). The responseof the Thai government was to declare a war on drugs in early 2003 (Human Rights Watch, 2004; Vongchak et al., 2005) and again in 2008 (Human Rights Watch, 2008). This zero-tolerance policy emphasized incarceration Page 1 of 11
2 Page 2 of 11 N. Willard et al. of drug dealers and compulsory treatment for drug users under a new drug policy known as the Narcotic Rehabilitation Act (UNODC, 2003). Despite these drug-suppression efforts, demand for and availability of MA remains persistently high (UNODC, 2008). Additionally, the zerotolerance efforts may in fact be exacerbating unintended consequences such as a shift to other licit and illicit substances, increased risk behaviors, reduced access to care and a rise in related sexually transmitted infections (STIs), HIV and other negative health outcomes such as increased alcohol use (Celentano, 2003; Poshyachinda et al., 2005; Vongchak et al., 2005; Sherman et al., 2006; Assanangkornchai et al., 2009; Werb et al., 2009). Furthermore, a large number of MA users are detained in prisons prior to being sent to treatment centers increasing their chances for exposure to HIV (Thomson et al., 2009). In response to this, and out of concern for human rights abuses, there has been a call from the international arena, including the public health field, human rights advocates and others, to take a different approach to drug use among youth (Celentano, 2003; Human Rights Watch, 2004; Daosodsai et al., 2007; Rhodes, 2009). One alternative to criminal justice is focusing on structural determinants of drug use. Structural determinants are aspects of the risk environment such as policies, laws, resource availability, organizations and the built environment that operate outside of the control of an individual and influence behavior (Blankenship et al., 2000; Burris et al., 2004; Rhodes, 2009). Such a focus recognizes and targets the underlying influences, or root causes, related to substance use, including unstable housing, economic issues, access to health care and police practices (Bluthenthal et al., 1997; Maher and Dixon, 1999; Kerr et al., 2003; Burris et al., 2004). Addressing structural determinants encourages a shift from focusing on individuals as solely responsible for drug use and associated harms to allowing for a much broader scope of opportunity for intervention across many sectors and systems of society. Addressing deeply entrenched issues with a focus on structural determinants requires the support and participation of community members from diverse sectors (Roussos and Fawcett, 2000). Community mobilizing and coalition development have been important vehicles when pursuing similar intractable and deeply rooted health concerns such as violence, pregnancy and chronic disease (Sege, 2004; Butterfoss et al., 2005; Kegler et al., 2009). This approach elicits diverse participation and perspectives, promotes the development of common goals and allows the community to pool resources and to take shared action in order to seek comprehensive solutions (Treno and Holder, 1997). Engaging community members in planning and problemsolving to benefit their community allows for infusion of local values and needs, problem-solving on multiple levels, and encourages adaptation and increased chances for sustainability of changes (Strader et al., 2000; Minkler et al., 2003). Diverse community involvement provides the opportunity to bring together those sectors that may be targeted for change such as health and social services, business, faith, government, education and others. In Thailand, community organizing has been used to address such health related-community development issues as HIV/AIDS stigma and drug abuse. Village-level empowerment and mobilizing have identified links between HIV/AIDS and issues faced by the community at large (Apinundecha et al., 2007). Development of a village-level intervention for drug use resulted in primary, secondary and tertiary community-wide prevention support, including methadone treatment for addiction (Keawkingkeo, 2005). In both cases, the approach to engage local community in problem-solving resulted in a recognition that these are community issues, not problems of individuals and their families. Family planning national-level initiatives that relied on community engagement took a bureaucratic rather than a participatory approach with decisions and planning at the provincial or regional level, resulting in fertility performance targets for field staff, thereby failing to address community and family issues (Askew and Khan, 1990). Advancing MA prevention in Thai communities with a focus on addressing structural determinants will require shifting resources and developing new community infrastructure. Diverse participation with local community engagement as well as mid-level government involvement will be necessary. Furthermore, community context matters in the coalition makeup. For example, who the key partners are, past history of collaboration and geography (e.g. rural versus urban settings) have influence on the diversity of partners, coalition infrastructure, and its functioning (Kegler et al., 2010). In this paper, we describe the adaptation of the US-based Connect to Protectw (US C2P)
3 Addressing structural determinants of methamphetamine use Page 3 of 11 model for coalition development addressing HIV-related structural determinants for youth (Ziff et al., 2006), to coalition development in Thailand to address structural determinants associated with youth MA use. We chose this approach of community engagement, coalition development and capacity building for the Thai communities in order to alter the centralized, top-down decision-making process that is indicative of the war on drugs approach. Community mobilizing is a democratic movement to create sustained empowerment at the grassroots. The risk in this approach is that true power shifts may not take place or may not be sustained. We attempted to ameliorate those risks through strategies described in this paper that include ensuring centralized government endorsement and commitment with advisory-level engagement. Furthermore, examining the adaptation of a US coalition model that encourages diverse participation and alternative strategies to the Thai context may help define the broad similarities in building coalitions, such as the need to strategically develop buy-in with key constituencies and engagement of appropriate community sectors, as well as differences in the details of how to identify partners and who they are. US C2P model C2P is an HIV community-level prevention model allowing communities to assess risk environments and to develop a coalition of diverse s that strategically plan for and bring about changes to systems and institutions (Ziff et al., 2006; Geanuracos et al., 2007; Straub et al., 2007; Deeds et al., 2008). C2P is grounded in theories of community mobilizing (i.e. group identification, collective problem-solving and action) with a focus on making structural changes (intermediate outcomes) defined as changes to policies, practices and laws that lead to improved health outcomes (ultimate outcomes). The mobilization effort hinges on the ability to bring key people to the table that can identify structurallevel solutions and those that can act as key change agents (Blankenship et al., 2000; Fawcett et al., 2000; Roussos and Fawcett, 2000; Sumartojo, 2000). C2P coalitions were developed in 2006 and are currently active in 14 US cities. C2P differs from community-based efforts such as Project Northland that has prescribed intervention elements implemented in sequential phases (Perry et al., 2002). Similar to Communities that Care and Communities Mobilizing for Change On Alcohol, the C2P model provides an infrastructure for planning, prioritizing and action that expects planners to consider the entire community context when identifying and implementing solutions (Wagenaar et al., 1999; Hawkins et al., 2008). One challenge with this approach is the ability of coalitions to formulate strategic plans that target appropriate needs resulting in desired outcomes (Butterfoss et al., 1996; Roussos and Fawcett, 2000). To assist coalitions in focusing their plans, C2P utilized two key tactics to identify and target deeply embedded causes within systems, structures and the environment. The first tactic was to outline a specific definition for structural change that included four components: (i) new or modified policies, practices, laws, programs and changes to the physical environment; (ii) must be logically linked to the health outcome; (iii) may directly or indirectly impact the individual; and (iv) must be sustained beyond the involvement of the coalition. The second tactic had coalitions apply a rootcause analysis process to examine the spectrum of circumstances contributing to poor health outcomes (Willard et al., 2012). Root-cause analysis, emanating from the field of injury prevention, allows problem-solvers to dissect the proximal causes of injuries to determine the underlying system-level causes of risk by providing an iterative process to penetrate deeply into problems to examine a wide range of reasons why the problems exist (Altman, 1994; Wu et al., 2008). As an example, a community may determine that increasing HIV rates are related to limited access to care. The coalition then works with a local clinic to expand hours, influences the school board to allow testing vans at schools and changes legislation regarding insurance eligibility for minors. The community determines that men with unknown HIV status are being discharged from prison and the coalition works with the prison and health department to establish testing, treatment and continuum of care protocols upon discharge. The initial partner-selection process included conducting an environmental scan and cataloging of community agencies followed by in-depth interviews with select individuals that resulted in partnership formation with s from community-based organizations (68%), government agencies (14%) and faith-based organizations (9%) (Straub et al., 2007). As strategic plans developed to target complex root
4 Page 4 of 11 causes, coalition membership developed to include directors and bureau chiefs of government agencies, executive directors, city council members, judges, police and elected officials. Coalition development allowed for varying levels of participation (i.e. main, supporting and advisory roles). Partners signed a non-binding memorandum of understanding (MOU) that formalized the partnership by outlining roles and responsibilities. Results have been significant with coalitions accomplishing more than 250 structural changes. This includes examples such as Puerto Rico amending Law 81 expanding HIV testing to youth under 21 years of age without parental consent; the Miami-Dade Regional Juvenile Detention Center began linking HIV positive detainees upon their release to medical care, including transfer of medical records; and Washington, DC, high schools requiring comprehensive sex education curriculum (Chutuape et al., 2010). METHODS N. Willard et al. Adaptation process Using the US C2P manuals, trainings and tutorials, the team determined the relevancy of the U.S. process to the Thai context and retained C2P key elements, while altering aspects of C2P procedures and materials. Contextual issues included: rural versus urban settings; differences in resource and service availability; need for Thai government endorsement versus competing health issues and coalition saturation in the US Key elements included geographic target selection for focusing coalition efforts; strategic planning using root-cause analysis, retaining the C2P definition for structural changes, development of a logic model outlining social and structural risk factors contributing to MA use; a coalition partner identification process relevant to rural, northern Thailand and retaining the three-tiered level of partner involvement. C2P Thai model This is a randomized control study design with three intervention districts and three control districts. The districts are located in the northern province of Chiang Mai in rural and semi-rural settings. Districts are divided into sub-districts that consist of many villages. While decisions are often made at the national level and disseminated through provincial, district, sub-district and village level, sub-districts have locally elected officials that have significant autonomy over decision-making, budgets and tax collection. District selection within Chiang Mai Province was based on epidemiologic profiles based on distance from Chiang Mai city, number of youth and young adults aged 14 29, economic characteristics; prevalence of drug and alcohol use; STI/HIV prevalence; MA arrest rates; and availability of health and social service organizations. Six districts were selected that had similar profiles and were then randomized into either the intervention or the control group. The Thai coalitions were developed to meet three characteristics: (i) s from the health, police, education and district-level government sectors with additional sectors as appropriate (e.g. community organizations, religious leaders); (ii) stakeholders who were geographically dispersed and (iii) those who were interested in participating and willing to participate in the coalition. A single member could meet more than one of these characteristics. The epidemiologic profiles used for district selection and baseline youth survey data were presented to government and community leaders to demonstrate that, despite intensive police force, MA was widely available, that use persisted and that risks associated with use were evident. This provided the basis to build the support and endorsement for a different approach, one that was based on coalition work to identify structural solutions grounded in public health and human rights principles. The first step in coalition formation was for each of the two to three member research teams to conduct interviews with five to six key informants per intervention district to identify potential partners. Key informants held positions such as members of a community advisory body monitoring local research activities, deputy district chiefs in charge of district operations center to combat drugs, and nurses conducting program interventions with MA users. Key informants were asked to name individuals who they felt could connect to and engage with varying levels of people, contribute to accomplishing districtlevel structural changes (i.e. make decisions and manipulate resources), were from varying community sectors, prioritizing the education, health and police sectors with other sectors as
5 Addressing structural determinants of methamphetamine use Page 5 of 11 appropriate (e.g. religious leaders, community groups, youth leaders), and were well respected. The names and rationale for why key informants felt these individuals were appropriate for partnership were catalogued. A key actor mapping exercise was then completed to create a visual map of how the different sector s related to one another and what role they played relative to each other. Potential partners were first coded by the sector that they represented and then plotted on a map to indicate the sub-districts where they had roles and responsibilities (i.e. holds or has held a position at the district, sub-district(s) or village level). The team then conducted informal, semistructured conversations with named individuals to determine their level of interest in the coalition work and thereby the role each partner would play. Individuals were asked about their perceptions of MA use, what the community could do jointly to positively influence youth culture, past experiences working as a member of a planning team and ability and interest in committing to the coalition. The final partner list was then reviewed to consider the three-tiered membership structure as follows: (i) main partners were able to commit to the initial planning period (i.e. six to eight capacity building meetings culminating in identifying structural changes and developing action plans to accomplish these changes), (ii) supporting partners did not commit to attending all meetings but were committed to supporting the coalition over time and (iii) advisory partners were people in high levels of authority who may not have time to commit to early coalition work but were necessary for endorsement of the project and may play an important and influential role once structural changes had been identified. The final step in formalizing the partnership was the signing of a non-binding MOU. Each MOU was signed by district government officials, a partnering member and senior project staff from Chiang Mai University. The MOU served several important functions: (i) it provided the opportunity for formal endorsement of the coalition by the district government, (ii) it outlined a mutual agreement that law enforcement and health sector involvement was necessary for comprehensive problem-solving and (iii) it framed the coalition work in terms of focusing on root causes of structural-level determinants for MA use grounded in health and human rights principles. In order to monitor for fidelity to the model, the Thai team submitted routine reports to the US team that included details of the partnering process and rationale for decisions. Once coalitions were established, and developing their strategic plans, Thai team reports included structural changes being considered by their coalitions. The USA and Thai teams jointly reviewed these proposed changes to determine that they met the C2P definition in addition to be stated as SMART (Specific, Measurable, Achievable, Relevant and Timely). If a proposed structural change did not meet these criteria, the group discussed alternatives to reaching the same goal. This often entailed breaking large ideas into smaller components for several single, measurable structural changes. The Thai team provided this feedback to the coalitions to facilitate further honing of ideas. The team also did routine monitoring of the control districts to document community changes that may influence outcomes and that will be accounted for in final analyses. The study included process evaluation of the coalition development, functioning and progress in identifying and accomplishing structural changes. Outcome evaluation consisted of conducting surveys with a sample of youth in both intervention and control communities randomly selected at baseline, midpoint and at study end to assess changes in risk behaviors association with MA use (e.g. reduced MA use, older age at initiation, reduced frequency of MA use). Qualitative, in-depth interviews were conducted at midpoint and the end of the study with a single, sub-set cohort of randomly selected youth completing the midpoint surveys to assist in gauging the effects of changes on risk at the individual and community level. Additionally, the staff compiled extant data at study end to assess changes in community indicators such as arrest rates, school retention and disease incidence and to assess new or expanded care and services. Data presented here are from the initial step in forming coalitions. This research was reviewed and approved by Institutional Review Boards at the Research Institute for Health Science at Chiang Mai University and Johns Hopkins Bloomberg School of Public Health.
6 Page 6 of 11 Materials For this paper, we reviewed the Thai C2P manuals and materials (e.g. key actor maps and research staff memos), including reviewing partnering procedures and selection criteria. The Thai team collated and translated data from these sources to summarize the partner-selection process and the final coalition make-up. RESULTS N. Willard et al. A total of 16 key informants were consulted, with seven representing the health sector, two from the police sector, two from district government, two from village-level leadership, one youth leader, one non-governmental organization and one faith-based. Overall, 77 potential partners were named by the key informants. The project staff reviewed the key actor maps and input from key informants to narrow the list to 63 individuals ( 20 per coalition) for initial partnering. Decisions about who to involve in this early stage of coalition development included individuals who were potentially able to have influence over many subdistricts and/or the entire district, who represented varying sectors, and who were well respected in the community. Of the 63 chosen for partnering, 59% (n ¼ 37) had potential influence in one sub-district, 13% (n ¼ 8) had potential influence in two to five sub-districts and the remaining 29% (n ¼ 18) held district-level positions. District governors from each of the three intervention districts were formal partners. There were a total of 10, 12 and 13 sub-districts in the three intervention districts. Fourteen potential partners were eliminated because their expertise was not related to youth and drug use or they did not demonstrate influence in the target areas. When making final partner selections, 59 people were offered partnerships. Four individuals were dropped from final partner consideration because they were being transferred to another district or refused to participate in the coalition work because of lack of interest and/or time. Final partner makeup included 25% from the health sector, 22% from the sub-district-level government and 10% from each of the religion, education and police sectors. Advisory partners included three district governors, two heads of district health offices, two directors of district secondary schools, a coordinator from a Global Fund recipient organization and three sub-district governors. These advisory members were included because their staff were invited to be the main or supporting partners and because of their prominent leadership roles in the community that may be important for future structural changes (Table 1). The coalitions have developed structural changes in several sectors where there may be influence on risk factors associated with MA initiation and use, including making changes in schools, health care, community support and youth development. Changes within the school systems were focused on promoting retention of at-risk students by including setting minimum student-retention expectations. Applying rootcause analysis, revealed that services and support were needed to assist schools in addressing student retention and included in their strategic planning were structural changes such as peer mentoring programs, reconciliation and counseling services. The coalitions are also establishing assessment and referral mechanisms to identify and effectively manage at-risk youth. Initiatives spanned local schools and village settings to district-wide changes and have brought varying sector s to the MA prevention work. Another focus area has been development of services for substance use treatment and prevention resulting in a new drug treatment clinic and establishment of a community center that offers a myriad of services to support the community in identifying and addressing issues related to MA use. Monitoring of control communities showed no indications of mobilization, coalition formation or similar institutional initiatives during this study period (Table 2). DISCUSSION Research on coalitions has demonstrated that there are contextual influences on coalition development and functioning, including history of collaboration, geography, local norms and values (Kegler et al., 2009) as well as community readiness for change (Wolff, 2001; Chilenski et al., 2007). Coalition formation entails bringing a core group of local actors together who have a shared perspective and commitment; this core group then acts as a catalyst to mobilize the broader community (Butterfoss et al., 2005; Kegler et al., 2009).
7 Table 1: Coalition partnering process Health Police Religion Education District government Sub-district government Village government Youth NGO Community organization Total Potential partner identification Number of potential partners within each sector named by key informants San Sai Sankampaeng Mae Taeng Total (%) 17 (22) 7 (9) 7 (9) 9 (11.7) 4 (5.2) 15 (19.5) 4 (5.2) 7 (9) 4 (5.2) 3 (4) 77 Number of potential partners within each sector who were chosen for semi-structure conversations San Sai Sankampaeng Mae Taeng Total (%) 15 (24) 6 (9.5) 6 (9.5) 7 (11) 3 (4.8) 13 (2.6) 3 (4.8) 6 (9.5) 2 (3.2) 2 (3.2) 63 Number of final, selected partners within each sector San Sai Sankampaeng Mae Taeng Total (%) 15 (25) 6 (10) 6 (10) 6 (10) 3 (5) 13 (22) 2 (3.4) 4 (6.8) 2 (3.4) 2 (3.4) 59 Main Supporting Advisory Total Final partner makeup by role Health (25.4) Police (10.1) Religion (10.1) Education (10.1) District government (5.1) Sub-district government (22.3) Village govternment (3.4) Youth (6.7) NGO 2 2 (3.4) Community (3.4) organization Total (%) 16 (27.1) 22 (37.2) 21 (35.6) 59 Addressing structural determinants of methamphetamine use Page 7 of 11
8 Page 8 of 11 N. Willard et al. Table 2: Summary of initial coalitions strategic planning and accomplished structural changes Community sector targeted for change Geographic implementation Sectors/systems involved in design/implementation School-based structural changes Four activities to assist at-risk students to complete compulsory education: (1) Reconciliation system to work with students at risk for expulsion due to history of peer conflict and violence (2) Kru-Por-Mae: Teacher plays role as the student s parent; a teacher will be assigned to take care of several students from different grades (3) Counseling services provided in school (4) Friend helping friend peer support program Routine screening for at-risk youth that includes screening for family problems, sexual risk, drug use, peer conflicts and poor academic performance We Love San Khumpaeng Network Includes a network of community people committed to problem-solving regarding youth substance use, sexual risk, school dropout and unemployment Health care Establishment of a new clinic for harm reduction and treatment for substance use Community-based support Public service unit A community-based center with services to assist villages to identify people current drug users and work with families to solve drug and related problems by allowing choice of education, occupation, healthcare, treatment and/or rehabilitation Youth development Youth committee appointed by sub-district governor as part of the sub-district policy and planning work structure: Inclusion of youth development plan in sub-district long-term plan Developing drug use and sexual risks prevention programs for youth Establishing youth fund to support youth activities Other Policies regarding no alcohol at religious events Launched in six schools and then expanded to all district schools Adopted by a second district and Chiang Mai city school district District level District level Sub-district Sub-district Initiated in five sub-districts within on district; expanded to a sub-district in a second district Sub-district Teachers from participating schools Education Office Region 1, Chiang Mai District hospital District health office Temple/Monk representation Sub-district hospital School Education Office Region 1, Chiang Mai Parents Formal and informal community leaders sub-district government Provincial government School s including teachers Local health personnel Community leaders Sub-district Health Promotion Hospital District hospital Sub-district government Community s Sub-district government District government Sub-district hospital Community members Sub-district government s Sub-district headman Village headmen Sub-district education official Sub-district agriculture official Sub-district public health official Director of sub-district health promotion Religious leader Teachers from formal and non-formal education Youth s Sub-district government Community s Community organization to reduce alcohol consumption