| |
Introduction:
The Science of Healthy Behavior
Using research-based policies and strategies to promote health
and safety
"I began my career here in the early '70s working on a
burn prevention research project," recalls EDC Senior Vice
President Cheryl Vince Whitman. "At that time, people believed
that burns were not preventable—they just happened, and
there was nothing you could do about them. Through public health
research and epidemiological data showing the patterns of morbidity
and mortality, we developed an understanding of effective prevention.
We can prevent burns. We know that you can intervene in certain
places to make a difference, and we began to understand exactly
how to make a difference. For example, during a relatively
short intervention period, we were able to demonstrate significant
increases in parents' knowledge of the risks that scalds and
playing with matches pose to young children."
Senior Scientist Susan Gallagher has seen
similar progress in the field of injury prevention. "Twenty years ago, people
laughed at me when I talked about the use of car seats for children
as part of routine health care practice," recalls Gallagher. "They
said it would never happen." In the two decades since
then, she has seen the public health approach to injury prevention
lead to car seat requirements for children nationwide. During
those same years, many other injury prevention campaigns have
also made significant improvements in the lives and health
of
Americans, young and old-the widespread adoption of bicycle
helmets, seat belts, smoke detectors, and childproof medicine
caps are
just a few.
Today, these kinds of success stories provide the foundation for
the growing
field of prevention science—research-based strategies designed to promote
health and safety. The prevention work of EDC's Health
and Human Development
Programs (EDC/HHD) spans the spectrum, addressing public health challenges related
to alcohol, tobacco, and other drug use; HIV infection; injuries; and violence.
We work with communities; schools; and state, local, and national agencies in
both the United States and many other countries.
According to Vince Whitman, who oversees much of EDC's prevention
work in her
role as director of HHD, the field is at a crossroads: "The whole field
is in a different place than it was when I began. You can see the progress in
the rates of violence and drug use among teenagers, which are going down despite
a rise in the population of that age group. After these last few decades of research,
we know a great deal about what works. However, the strategies that we know work
need to be applied more consistently in schools and communities."
Many EDC/HHD projects focus on closing the gap between research and
practice by developing and disseminating research-based strategies
to institutions and
communities around the world. In this roundtable discussion, Dan Tobin discusses
that challenge with Vince Whitman; Lydia O'Donnell, director of EDC/HHD's Center
for Research on High Risk Behaviors; Renée F. Wilson, who serves as director
of several EDC/HHD projects that address the health and safety needs of urban
African American and Latino youth; Michael Gilbreath, managing director of the
Higher Education Center for Alcohol and Other
Drug Prevention; and Deborah McLean,
training and technical assistance manager for the Northeast
Center for the Application
of Prevention Technologies (CAPT).
Dan Tobin: Let's start with a definition. What do we mean
by a research-based strategy?
Deborah McLean: In community-based substance abuse prevention,
a rich body of research has been amassed over the last 30 years,
but especially in the last 10 years. We're now at a point where we
can identify about 140 "model" programs that have been
evaluated.
In general, a program designated as "research-based" has been reviewed
by a panel of experts who determine that the program meets a set of predetermined
standards of empirical research-such as, the program is based on theory, has
sound research methodology, and can show results that are clearly linked to the
intervention itself and not to extraneous factors. However, one of the dilemmas
we face is that different federal agencies use different standards to identify
what they consider to be a "research-based" or "science-based" approach.
Our funder, the Center for Substance Abuse Prevention [CSAP], identifies three
categories of programs: effective, promising, and model. An effective programhas met a host of CSAP criteria, such as, it has been published in a peer-reviewed
journal, or the intervention has been replicated or repeated in multiple settings
and has shown a consistent, positive pattern of results. Promising programs meet
fewer of those criteria. They may, for example, have produced positive results
but haven't been replicated yet in different settings. Model programs have been
recognized as effective and have been developed by a group that has agreed to
provide information, training, and technical assistance to communities that want
to replicate these programs.
Michael Gilbreath: In the field of higher education, until
recently, there has been little formal, rigorous research. There
is now a growing body of work, including some of the work of the
Higher Education Center [HEC], that does meet that standard. In the
past, we've had to focus primarily on promising practices. Now, we
are in a position to disseminate formal research results on the effectiveness
of alcohol and drug prevention strategies specific to college campuses
and college communities. That's one of the key roles of HEC.
Cheryl Vince Whitman: I think we should draw a distinction
between an effective strategy and a research-based strategy. There
are a number of strategies that the field would generally say are
effective, even without a formal, completed study. One example is
the move in the last decade by all states to raise the legal age
for alcohol sales to 21. During that same time period, we have seen
a 40- percent reduction in traffic-related car fatalities involving
people under 21. That's a very significant reduction. Now, we can't
prove that the law is responsible for all of that reduction, but
clearly the law has done a lot to stabilize the problem of drinking
and driving by young people. And HEC builds on that strategy. We
work with the campus community, police, and the local community to
enforce age-21 laws and cut down on access and consumption.
DT: Lydia, you have carried out a number of formal research
projects. What is your definition of a research-based strategy?
Lydia O'Donnell: Prevention science is a relatively new field,
in which we look at complex health and social issues. This kind of
research is a lot messier than other kinds of research, such as research
to see if the polio shot works or math scores improve. As a result,
it has been difficult to identify what kinds of prevention strategies
really work. But there are some things we do know-and we're beginning
to get that data out to the field. We're at a point now where two
strands of questions are coming together. The academic research community
has been pursuing the question, How do we develop data-driven programs
that are culturally relevant and produce measurable outcomes? At
the same time, federal agencies are asking, What have we learned
from the research base that we can share with schools and communities
now—before opportunities are missed, before people
die?
Renée Wilson: The agencies are also responding to
questions from the field about how to make sense of all of these
different programs. There was a time, not long ago, when people were
just using whatever approach made sense to them. Now, with so many
programs out there, the question becomes, How do I choose?
DEMAND
DT: Why is everyone selling research-based strategies to
schools and communities? And why do people want them? Is it a way
to get
grant money, or do they genuinely want something that works?
RW: I think it is more that they want something that works.
In most cases, I've found that communities appreciate the expertise
that is provided by researchers and evaluators. For instance, in
the Reach for Health research study, schools received funding to
set up a multifaceted health program that included a service learning
program, and a health curriculum that addressed major issues for
the community-violence, tobacco and other drug use, and early sexual
risk taking. Working with schools, we were able to show that middle
schoolers who participated in service learning were less likely
to become involved in risky health behaviors. With those findings
in
hand, the study schools are expanding similar programs to reach
even younger students.
DT: I am also wondering what the research-based strategy
is competing against. For example, I know that there have been
studies of DARE
that raise questions about its long-term effectiveness, and yet
it is very popular. Maybe that's because everyone wants to support
the
police department, or maybe it's because it is easy to implement.
If I'm a member of the school board or a community group, why not
pick something easy? Doesn't the complexity of some of the research-based
strategies make them a tough sell?
MG: I think DARE is an interesting example. You're right:
It has been established in schools for many years, to the point
where huge amounts of federal, state, and local resources go into
funding
it. But now there is so much interest in research-based outcomes—and
so many questions raised through evaluations of DARE—that DARE
has finally acknowledged that it has some problems. In fact, the
Robert Wood Johnson Foundation is investing in revamping DARE in
a way they hope will strengthen the program and produce positive
results.
But let me go back to your question about demand. In the higher
education field, the demand for programs comes from campuses looking
for something
that works.
There is a sense of desperation. They want to go beyond the traditional alcohol
awareness week or the "car wreck on the quad." We try to help them
focus their time and money on a collection of proven strategies.
CVW: From the school-based research we've done—both
here and internationally—we know that the best approach in a
school setting is a combination of two to four strategies supported
by overarching health policy for the whole educational environment.
Those strategies may include curriculum, community service, working
with the local communities, and cutting down access. One research
study says that if you take three or four strategies and target them
toward a common goal in one setting, you are much more likely to
make a difference than if you have one strategy, or if you have eight.
If you go beyond three or four strategies, the program becomes diffuse
and unfocused. You have to think about how to coordinate resources
so that they work together toward a common goal, rather than competing
with one another.
FIT: REPLICATION VS. ADAPTATION
DM: The issue of community resources is taking on increasing
importance in the work of the CAPT. When we first started three
years ago, many communities were contacting us, simply looking
for a list
of model, science-based prevention programs. As our work has evolved,
we have developed a set of questions that encourage communities
to look more deeply at the programs on the list. We use the list
as
a starting point for a conversation about a whole host of factors
communities need to consider before selecting a program. For example,
they need to look at the fit between the program requirements and
their capacity to implement the program. Does the program complement
existing programs? How will the target population react? Is the
program sustainable?
LO: The fact that you are asking those questions is a major
change in the landscape of prevention work. When I first came to
EDC, nearly 20 years ago, funders were basically paying for the
development of model programs. When a program was finished, there
was this expectation
that you put the word out and whoever wanted to use the program
would get it and use it. It shouldn't have been rocket science
to realize
that this wasn't the case. People just don't take packages from
the shelves and use them. We're seeing increased awareness around
questions
like, "What kind of infrastructure, support, training, technical
assistance, and just plain cheerleading do communities need to adapt
a program and make it their own?" And, "What do we really
mean by 'making it your own'? How many changes can a local community
make to a program and still claim that 'the program' is effective?" Nobody
knows the answer to that. That's what makes it so difficult to
identify effective programs.
DM: From my experience, researchers are failing to give
communities enough guidance about how to take some components of
a program out
of the box, implement them, and test them. Where can communities
make adaptations to a program without compromising the integrity
of the program? What if the community can only afford to offer
15 workshops instead of 20? All kinds of compromises get made in
order
to implement the program in communities with cultural, political,
and economic realities that may be different from the ones that
existed in the controlled studies.
MG: Putting out good information or a model program doesn't
create change in and of itself. You also have to address the issue
of resources and the environment in which the program will be implemented.
In HEC, we take people who come out of health backgrounds, counseling
backgrounds, and student services backgrounds and turn them into
organizers and advocates for a different perspective. That requires
figuring out how to get the president of the campus involved, how
to get the community's police department working with the campus
police officers, etc. [See the related
story on HEC's environmental approach.]
CVW: Without that kind of community support, many proven
strategies will not be effective. I'd like to bring up an example
from a different
setting. Several years ago, we worked with hospitals on a violence
prevention program. We knew from our work in alcohol and tobacco
abuse prevention that it can be effective to have physicians talk
with patients about changing their behavior. The message, coming
from an authority figure who has a relationship with the patient,
can produce a change in behavior-provided that there is some ongoing
support in the family and/or community. We took that same strategy
to the arena of adolescent violence prevention. We worked with
physicians in Boston who were treating adolescents, and we focused
on their
approach to routine visits with teenagers. We prepared trainings,
materials, and protocols to motivate and equip health care providers
to speak with their patients about their aggressive behaviors,
such as taking weapons to schools or getting into fights. Physicians
were
willing to bring up the issues with their patients, but that was
about all they could do. At the time, there weren't programs in
the community focused specifically on adolescent violence prevention,
so they couldn't make a referral. Out of that research, we developed
the Boston Cares project, which has created a follow-up referral
and support system in the community to help prevent injury and
violence.
LO: Part of the role we play is to provide a two-way connection-both
within schools and communities and between communities and funders.
The funders have supplied millions of dollars for research and
for resource centers to get these effective programs out to communities.
In our roles, we are coming back to the funders and our research
colleagues and reporting on what we're hearing from communities.
We are trying to broaden the conversation to take into account
what
it really means to adopt and adapt things at a local level.
READINESS
MG: One of the things we're learning from schools and communities
is that a lot of good approaches are still sitting unused on a
shelf. It used to be a training manual sitting on a shelf. Now
it is a task
force on the shelf. That task force stops functioning if there
is no ongoing dialogue about implementation, overcoming barriers,
etc.
We work with and prepare groups to assess and act on the information
coming from the research community.
DM: It's the age-old adage of beginning where schools and
communities are at and moving them to where they want and need
to be. If, for example, a community is about to implement a prevention
program, then people will need help with the social marketing necessary
to sell the benefits of the program to the community.
CVW: I would add another adage and that is the 80/20 rule:
Unless you spend 80 percent of your time with the concerns of your
ultimate users, you have only a 20 percent chance of succeeding.
We also need to address the issue of organizational climate. We
tend to focus on the characteristics of the community, but we also
need
to consider the characteristics of the agency implementing the
program. Is the leadership fully committed to the program? Have
they dedicated
the time and resources to it? The organ-ization is the delivery
agent. It's like the needle for a vaccine: If the syringe doesn't
work,
you can't deliver the vaccine.
OVERARCHING APPROACH
DT: How
similar does your work look across all the different domains
you work in—substance abuse, violence prevention,
injury prevention, HIV prevention? Is there a common approach to
prevention across all
of these domains?
DM: Based on our review of science-based programs, three
keys to effective substance abuse prevention guide our work. The
first
key is encouraging schools and communities to use approaches that
are based in theory and research. The second key is encouraging
them to use multiple strategies in multiple settings, coordinated
toward
a common prevention goal. The final key is encouraging schools
and communities to design and implement programs that take into
account
community resources as well as community needs. Can they carry
out the program-including conducting a strong evaluation? Will
they have
the data to demonstrate whether their program is effective?
LO: It depends what kinds of projects you are talking about.
For example, in our HIV prevention work with community-based organizations,
the term "organizational development" doesn't quite apply.
They aren't at that level.
DT: What do you mean?
LO: The school system you are working with is very likely
going to be there for decades. The community organizations may
not have that same assurance of longevity, or the same level of
stability.
They are more loosely organized. They have tremendous turnover
in staff. If you go to a hospital or a clinic, you find much more
infrastructure
than you do with a community organization.
RW: I think that raises important questions for us about
the selling of research-based strategies to these kinds of organizations.
What can we do to provide them with the kind of assistance they
will
need while they are implementing a program? They may not be able
to conduct research or continue with an evaluation.
CVW: All of our work addresses these environmental and resource
issues while also focusing on the health of individual people.
At the most basic level, all of our prevention work builds on some
fundamental
human desires. Every parent wants his or her child to succeed in
reading, in math, in science so that the child will have opportunities
later in life. All parents want their children to be safe and healthy.
Nobody wants to lose a child in a car crash; nobody wants his or
her child to become infected with HIV, or to have an unintended
pregnancy. So the real argument for research-based prevention comes
down to
the human desire to keep children, adolescents, and adults healthy
and able to learn and enjoy life. And that desire is shared by
health practitioners, teachers, and police officers as well as
parents.
They all want to do things that make a difference in people's health
and well-being.
For questions or comments, contact mosaic@edc.org.
Copyright 2000-2003
Education Development Center, Inc. All Rights Reserved.
|
