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I want to commend NIDA for holding this important conference. And, to demonstrate how important the Center for Substance Abuse Prevention believes this conference is, we are here in full force. There must be 30 members of the CSAP staff participating in this conference. We are going to gain a lot from it, and I am pleased that Alan Leshner and his staff have organized such an outstanding event.
My topic is bringing together science and the community and bridging the gap. Most recently we have seen a dramatic increase in the public's awareness of the problems caused by substance abuse and also in society's willingness to act to reduce these problems. Now, because of the media and the election, private citizens and public officials have become more willing to take on prevention and make it a personal and a national priority.
You heard from General McCaffrey, and I am sure he mentioned to you that prevention is the number one objective in the national drug control strategy. We now have a growing body of research that gives us important insights about the causes of drug problems as well as about effective strategies to prevent them.
Also, we have to keep in mind - as you have heard over time from Dr. Leshner and others - that we can measure our progress in numbers, because fewer Americans use illicit drugs than did so more than a decade ago. Looking at the area of smoking in the American population, we have seen a decrease, as well as for alcohol-related traffic accidents. The thing to keep in mind is that 78 percent of young people are not drug users. That says a lot for our field, whether we are prevention research scientists or prevention practitioners who are on the front line. We have made considerable progress.
This progress is encouraging, but at the same time we must be aware that drug use is not a problem that ends and that prevention is not a job that gets finished. I remember one of our Presidents who talked about "turning the corner," but we know now that to be a fallacy, because there is a need for sustained, vigorous prevention efforts. It comes home to us when we look at the latest National Household Survey that has shown a major increase in marijuana use among those between 12 and 17 years of age. So we have to bolster our determination to maintain strong prevention efforts over time, and we must make them more efficient and more cost-effective, especially in this era of fiscal constraint.
The knowledge resources of the scientific community also must be applied to prevention practice. At the same time, scientists must become more aware of the crucial knowledge base that practitioners have accumulated through years of experience, and researchers must be sensitive to the practical needs as well as the limitations of prevention practice. Therefore, I would like to share with you some examples of CSAP's efforts to bridge the gap between science and
research.
CSAP currently supports three cross-site evaluations. There is a large community partnership program that started in 1990 that has progressed the furthest. The community coalitions evaluation and the high-risk youth grants evaluation began in 1995. The high-risk youth grants included in the evaluation were funded in 1994 and 1995, so they are just entering their data collection phase. This evaluation is a time series, individual measurement design with participating and comparison groups of young people. The partnership program evaluation is a comparison group design measured at two points in time with individuals nested within communities. The community coalitions evaluation is a time series, community indicator design, with individuals hospitalized or arrested, but also nested within communities.
The grant programs that we have supported at CSAP have encouraged grantees to undertake model interventions at each site, depending on the needs and the capabilities of the grantees. Thus, the partnerships and the coalitions, as well as the high-risk youth programs, call for applicants to design their own prevention programs as long as each grant meets certain objectives stipulated in the grant announcements. The freedom of choice that went along with the programs provided the overall broader goal of empowering grantees, with the hope that successful efforts could be sustained beyond the period of CSAP's funding.
We wanted to make a difference in the community, whether it was systems change or individual and family change. The result has been different interventions within each grantee community. However, I want to point out that all communities have been recruited with the assumption that they will faithfully implement the same intervention at each site.
A community trial is run from a central vantage point that prescribes the nature of the intervention to be followed. So the mission of the community trial is to examine this common intervention in different community settings, and the fidelity to the common intervention is more important than any concern for community
empowerment.
The community partnership evaluation has collected a broad variety of data, including cross-sectional surveys of adults and young people and case studies of 24 partnerships over a 5-year period. The evaluation is aimed at addressing
two major questions: Do partnerships lead to a reduction of substance abuse in communities? How does such a reduction occur? The evaluation requires a combination of quantitative and qualitative data.
The data collection was completed last June, so now we have comparable sets of outcome data with two points in time for the 24 partnerships and their matched comparison communities. The surveys were large-scale efforts with about 300 adults and 100 youth who were surveyed in each of the 48 communities. Unfortunately, it was not possible to carry out the youth surveys in all of the 48 communities.
Remembering that data collection just ended in June, we must regard any preliminary results as just a peek at much more that is to come. Remember that the 24 partnerships were chosen randomly from the entire portfolio of grants, and we would not expect that every partnership would have succeeded. But preliminary results suggest that statistically significant lower levels of substance abuse were found for 8 of the 24 part-nerships, compared with the comparison communities, after controlling for the possible confounding effects of individuals' demographic characteristics, such as age, gender, and race.
A key part of the continuing analysis will be to determine the conditions within these partnerships that might have produced such results, along with a similar analysis of the partnerships where such results were absent. We also want to look at the hindrances to change as well as the facilitators of change in those particular communities, which could have been from a number of different factors, including how the program was implemented, the type of program, or economic conditions. Therefore, in further analysis we will be able to speak to that point as well.
Among the important prevention activities instigated by the partnerships, developing and implementing local policies may be just as important as operating more traditional prevention activities, such as after-school programs, workplace programs, and alternative programs for young people. The evaluation will be exploring these and other potential explanations for partnership success or failure in months to come.
The community coalitions evaluation has a more complicated task than the community partnership evaluation. CSAP defines coalitions as clusters of single partnerships, and in turn, clusters of single organizations. From a prevention perspective, the coalitions are expected to be more far-reaching than the partnerships because coalitions are larger and contain partnerships within them. Coalitions cover a larger geographic area or target population and can include a wide range of prevention and prevention-related initiatives. One of CSAP's expectations is that successful coalitions will lead to a variety of desirable health-related outcomes and will not be limited to only reductions in substance abuse.
All of these complexities create a great challenge for the research team that must attempt to develop causal attributions under more layered conditions, especially when looking at a structure as complex as the coalitions. The evaluation design has just been completed, and the data collection is now under way. I know that some of you in the audience were instrumental in helping us put together the evaluation of the coalitions and the partnerships, and we certainly are appreciative, because it is difficult to develop an evaluation design for such a complex, structured prevention initiative. The data will be a combination of archival data available from national sources, State sources, and the coalitions themselves and will include hospital discharge data, uniform crime reports, and data from the fatal accident reporting system.
Note that this data collection plan does not include the conduct of surveys, such as surveys of young people in schools. Many researchers in the audience are aware that such surveys have become increasingly difficult to implement because of restrictions by local school districts and are further jeopardized by proposed Federal legislation. Such restrictions were the reason that CSAP could not cover all of the intended communities in the partnership evaluation.
At the same time, a benefit of the coalition evaluation plan is that it can cover a large number of coalitions. The plan analysis also will raise again the issue of optimal statistical models, because the data will have individuals who will be discharged from hospitals or arrested under varying law enforcement conditions nested within communities.
Whatever the model of choice, the analysis will likely have similar characteristics. I will walk you through a theoretical framework that we have used to evaluate Harvest Youth Programs, which include programs that were funded in 1994 and in 1995. From this large pool, we have selected 48 grantees, each with an experimental or quasi-experimental design. Data [collection] for this evaluation began last spring. The evaluation design is sensitive to the importance of program characteristics for providing a context and making comparisons between program participants and between comparison subjects. Also, in terms of subject characteristics, the fundamental questions posed in this quasi-experimental design involve comparisons between the study subjects and the comparison group. The framework also includes data on exposure of youth in the treatment group to specific strategies and services, and the analysis involves comparison of change and attainment of short-term goals.
In terms of followup, the design includes measurements of the level of treatment exposure after the prevention interventions have taken place. In terms of risk and resiliency outcomes, the variables represent the more long-term impact of the program.
The high-risk youth evaluation focus is on both intermediate outcomes and outcomes related to lower prevalence [of drug use] among the groups. Data will be collected from a variety of sources, including a youth survey. Our basic design elements are a multisite, quasi-experimental study with comparison groups and an integrated process and outcome approach. This design, like the partnership and coalition evaluation, recognizes the important role of qualitative findings and intermediate outcome findings in a successful interpretation of ultimate program outcomes.
The evaluation encompasses all 48 local programs with 24 programs from the 1994 cohort and 24 programs from 1995. The design includes the use of a standardized instrument and standardized data collection through annual site visits to the participating grantees. It also includes longitudinal surveys of 6,000 participating and 4,000 comparison youth over four points in time: baseline at program entry, posttest at program exit, 6 months after program exit, and 18 months after program exit.
The core analysis of outcomes will focus on an explication of treatment effects on substance abuse attitudes and drug use, and the analysis will be conducted to assess immediate effects detected through analysis of change in substance abuse measures between baseline and program exit. The analysis will be expanded to also assess long-term effects detected through an analysis of change in substance abuse measures, such as the change between baseline and 6-month and 18-month followup, that can be attributed to program intervention. This large-scale evaluation study for our high-risk youth program is the largest that we have ever done.
I have talked about our community partnership and coalition programs, and I would now like to focus on our most recent program, our prevention intervention studies. This new study program is driven by the need to support diverse studies in a variety of communities, both urban and rural. This program is neither a demonstration program nor a community trial program. Rather, it is an applied prevention study intended to generate new knowledge about how to change the developmental trajectory of children at risk of substance abuse. It is a cooperative, multisite approach that is being used to assess the effectiveness of interventions to change identified predictor variables and to synthesize the results derived from this effort.
To ensure success, the initiative also calls for a national research coordinating center that will have responsibility to provide overall coordination and data management of the multisite research effort, conduct secondary analysis on data relating to the common predictor variables, and integrate the results across developmental stages. Instead of being a comprehensive program, the initiative focuses on the ability to develop and evaluate culturally and developmentally age-appropriate interventions targeting the development of social competence, self-regulation and control, school bonding, and parental caregiver investment over one of the four identified developmental stages.
We are beginning [to study the] very young with this program. High-risk youth programs historically have focused on adolescents, and now we are looking at preadolescents, starting with 3 to 5 years, then 6 to 8 years, 9 to 11 years, and 12 to 14 years. In examining the four predictor variables listed above throughout four developmental stages, the study attempts to address the following question: At what developmental stage does enhancement of each of the predictor variables prove most effective in preventing or reducing negative behaviors that are predictive of substance abuse?
This, again, is an experimental design, and it is required to assess the effectiveness of the interventions targeted at the four predictor variables for each one of the developmental stages. Each of the sites will target one age group. Both process and evaluation data will be collected from target and comparison groups over 2 years. The analysis of the data will be conducted in the last 6 months of the grant period. Depending on availability of funds, we plan a long-term followup study.
Finally, I wanted to spend just a few moments on the two community trial projects that we have been supporting with the National Institute on Alcohol Abuse and Alcoholism (NIAAA). It certainly is another exciting collaboration between scientists and prevention practitioners in communities represented by these two projects.
The first project, which has just been completed and is in its fifth year, was designed to apply the best science-based strategies available to reducing alcohol-related injuries and fatalities. The four strategies with the strongest research evidence of effectiveness in reducing injuries and fatalities were identified: responsible beverage service practices, vigorous efforts to prevent impaired driving through well-publicized law enforcement, a variety of strategies to reduce sales of alcohol to minors, and the use of zoning ordinances to reduce the density of alcohol outlets. Scientists worked collaboratively with leaders in each of the three communities to implement these strategies. Two of the communities were in California, and one was in South Carolina. The communities were culturally diverse and had about 100,000 residents each. The project was rigorously evaluated, including extensive data collection in these subject communities as well as the matched comparison communities. The grant resources that were expended under the community implementation part of the program were very modest. These were expensive projects, and both NIAAA and CSAP had limited funds for implementation. This effort has paid off, though, in statistically significant declines in alcohol-related injuries and deaths in those communities.
Another community trial project is the Communities Mobilizing for Change on Alcohol (CMCA), which involved seven communities in Minnesota and Wisconsin. Community organizers worked with citizens of all ages and from all sectors of the community to develop strategies for healthy and safe communities in which underage drinking would be less likely to occur. Rather than educating youth on how to resist an environment that encourages them to drink, communities actually mobilized for change on alcohol and sought to change those environments that encouraged underage drinking and contributed to overall alcohol-related health and social problems.
As you know, altering the environment involves change in many practices and policies regarding alcohol. By changing the environment that makes alcohol so readily accessible and glamorous, a community can reduce the degree to which young people are encouraged and allowed to drink alcohol. Ultimately, then, by addressing consumption of alcohol among youth, communities not only reduce car crashes, violence, and injuries and other health problems but also discover and develop capacities to address a wide range of issues.
A major effort within CSAP to bridge the gap between science and the community is contained in our National Center for the Advancement of Prevention (NCAP). While all of the efforts before us are important, this one is important because it is an ongoing effort from which I expect the entire field to benefit. About 3 years ago, CSAP established the center with the following goals: to conceptualize the prevention field in ways that will lead to appropriate application of scientific knowledge, synthesize scientific knowledge so that it can provide clear guidance to the prevention field, and customize the information so that it can be easily used by a variety of audiences in the States and communities. To accomplish these goals, NCAP has established a process for involving both the scientific community and practitioners.
NCAP products are selected on the basis of two equally important criteria. First, there must be a good, credible body of scientific knowledge, as identified by a panel of senior prevention scientists in the field and from NIAAA and NIDA. Second, the potential product must be useful to the field, as judged by a panel of field advisers drawn from the States and community organizations. Products are then developed with careful attention to their scientific accuracy. They undergo the same kind of rigorous peer review that would be carried out in a research journal. The products are reviewed also by the panel of field advisers to ensure that they are clear and applicable. They are adapted into a variety of formats to make them most useful to different audiences.
The important goal is to get scientific knowledge expressed clearly and in ways that can be most easily adopted into practice. These products are designed to help policymakers and practitioners make sound decisions about which substance abuse problems to address, which strategies to select, and how to implement them most effectively.
NCAP has also hosted lectures and workshops by experts, including scientists, policymakers, and practitioners on a variety of critical prevention topics. These lectures have been recorded so that a broader audience can have access to them, and NCAP is currently developing a series of research alerts to bring recent research to the attention of practitioners by disseminating brief, easy-to-read summaries of key findings. In these and other ways, CSAP hopes to facilitate better communication between researchers and practitioners and better use of prevention resources through the application of important scientific findings to prevention practice.
I think we have made a tremendous investment in generating new knowledge about substance abuse and ways of preventing it. All of this money and effort and commitment has yielded a great harvest for us. We now have a better understanding of substance abuse, its causes, and its cost. We have at our disposal an array of policy strategies that can have a powerful impact on substance abuse and [related] problems. We also know much more about a variety of prevention programs, how well they work, and what makes them work best.
As I pointed out earlier, we still have a way to go - NIDA in terms of its scientific work and CSAP in generating knowledge. But when you think about our field 10 or 15 years ago, we have come a long, long way in terms of developing a knowledge base. The time has come to make sure that this valuable and hard-won knowledge - and, believe me, it has been hard-won on a number of fronts - is applied in both Federal and State legislative policies and funding choices and in the prevention efforts of communities across the Nation.
I have heard Alan Leshner say many times that it would be great if our policies were based on scientific knowledge and not ideology. Maybe at some point we can get closer to that ideal. What I have attempted to do this morning is show how CSAP is trying to make this work, bridging the gap between our practice and research. It is a challenging test and one that we all need to continue to work on together.
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