the untapped power of community-school based prevention
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The Untapped Power of Community-School
Based Prevention
Mark T. Greenberg
Pennsylvania State University
First we must seek out the causes of mental illness … and eradicate them. Here, more than in any other area, "an ounce of prevention is worth more than a pound of cure." For prevention is far more desirable for all concerned. It is far more economical and it is far more likely to be successful. Prevention will require both selected specific programs directed especially at known causes, and the general strengthening of our fundamental community, social welfare, and educational programs which can do much to eliminate or correct the harsh environmental conditions which are often associated with …mental illness.
(Pres. Kennedy, 1963)IEY1SUM
Poor School Achievement
Poor Mental HealthAggression/
ViolenceEarly Substance
Use
Impulsive Action
Emotion Dysregulation
Insecure Relations w/ Parent, Teachers, Peers
Undesired Related Outcomes
Underlying Shared Constraints
Improving Public Health Through Education
Self-Control/Emotion Regulation Cognitive Abilities – Problem Solving Skills Building Attention and Learning Capacity Healthy relations with
peers and adults Safe, Welcoming, Caring
Classrooms
Resilience Factors that create Well-Being for Children
Core Challenge Scope of the Problems in “Rural” Populations
30-Day Cigarette UseU.S. Monitoring the Future Study, 2008 U.S. Monitoring the Future Study, 2008—among 8th-12th graders, 30 day cigarette use
8th Grade 10th Grade 12th Grade0
5
10
15
20
25
30
35
Non-MSA Other MSA
Per
cent
age
1. Implementing Programs with High Quality and Fidelity
2. Program Integration with Ongoing Programs & Activities
3. Building Sustainability of Programs, Policies, and Practices
Three Research and Practice Challenges that could be
impacted by Effective Community Coalitions
Effective Universal Programs
Social/Emotional Cognitive Violence Prevention Responding in Peaceful
and Positive Ways Interpersonal Cognitive
Problem Solving Promoting Alternative
Thinking Strategies (PATHS)
Increased Social Awareness/Social Problem Solving
Making Choices
Drug/Alcohol Prevention Life Skills Training Project Alert All Stars It Real
Family Focused Intervention Triple P Strengthening Families: 10-14
–Iowa
Ecological School Transition Project Child Development Project Good Behavior Game/Mastery
Learning
Multi-Domain Linking the Interests of
Families and Teachers Seattle Social Development
Project Incredible Years
What has been Accomplished:
The number of empirically validated (EV) preventive interventions and policies has grown substantially
RCTs have been crucial in legitimizing prevention efforts – although many programs still require independent replication
Reviews of these programs are now widely available
The easy work is done!
Types of Research
Type 1 translational research applies basic science discoveries to
intervention development.
The typical endpoint for Type 1 research is testing of promising new models of prevention to reduce risk and improve health
and well-being.
Type 2 translational research investigates factors, models, and processes associated with the adoption,
implementation, and sustainability of tested and effective prevention programs, policies, and
practices in communities, services
settings, and populations.
A Focus on Type 2 Translational Research is Key to Examining the Process and
Outcomes of CCs
Type Two Translation is research on factors associated with the adoption and utilization of scientifically validated interventions by service systems.
In the real world, translation of science-based practices often stumble, largely unguided, toward uneven, incomplete and socially disappointing outcomes.
Sustained, quality EBIs
Evaluated-not effective
EBIs
Public Health Impact on Substance Use Requires…
Not Evaluated
Rigorously demonstrated, long-term EBI impact is very rare (Foxcroft et al., 2003).
…greater use of evidence-based interventions (EBIs)
…sustained, quality implementation on a large scale
What Do We Want?
We want programs that are:
Cost Efficient (affordable)
Teachable (broad scale use)
Sustainable (over time, changing
events)
Effective Programs
Evidence-based programs are most effective when they are implemented with fidelity
Fidelity = the practitioners use all the core intervention components skillfully
Midwestern Prevention Project (MPP)Effects of Fidelity of Implementation
Cigarettes Used in the Last Month (N= 42 Schools*)
13.4% 13.4%
24.3%
15.3%12.2%
22.0%
0%
5%
10%
15%
20%
25%
30%
Perc
ent U
se o
f Cig
aret
tes
Baseline
Year One
Data from Pentz, Trebow, Hansen, MacKinnon, Dwyer, Johnson, Flay, Daniels, & Cormack
*Approximately 5,000 6th and 7th grade students @ baseline and follow-up
Questions About Sustainability and CCs
How can communities institutionalize prevention programming as they do treatment?
What factors can improve the sustainability or “staying power of prevention programming”?
What types of technical assistance do schools, agencies and community leaders need to create systemic change?
Creating CC Models to Insure Quality Implementation and Sustainability
1. Communities That Care
2. PROSPER
Sustainability: Definitions
Continuation of a program or policy following adoption; the last stage of implementation.
The incorporation of a change into everyday behaviors and beliefs.
“Making the change stick.” “Doing business in a new way”
Sustainability is a Process
Sustainability is a process. It requires buy-in from end users and leaders who have had sufficient experience to see the program work effectively in their context.
This requires 4-5 years of implementation. Thus, a long-term plan for training and support is essential to more toward sustainability.
Large Scale Diffusion of Research-Based Prevention: The Pennsylvania Experience
Investigators: Collaborative Policy Innovators:Mark Feinberg Clay YaegerMark Greenberg Mike Pennington
Building Community Coalitions
In 1992, PA Commission on Crime and Delinquency (PCCD) chose to use the Communities That Care (CTC) model
Developed by David Hawkins and Richard Catalano Mobilizes local communities by involving “key leaders” Establishes a prevention board to oversee local
prevention assessment, planning and implementation process.
Board develops a long-term prevention plan based on an assessment of risks in the community.
Communities That Care
Prevention Board members undergo a “six-phase training” on the CTC model:
Key Leader Orientation Community Board Orientation
Community Assessment Training Community Resource Assessment
Training
Community Planning Training Community Plan Implementation Training
Why CTC?
Why PCCD chose the CTC model: Community readiness – prepares “fertile
ground” to support a comprehensive community prevention effort before selecting specific programs.
Programming often selected based on the availability of grant funds – we have money so let’s do a program!
CTC turns this approach on its head – identify a need before choosing a program designed to meet that need.
Make sure that chosen program(s) fits with the risks and strengths of each individual community.
Provides a roadmap to ensure that programming leads to specific, measurable positive outcomes in the community.
PA Communities That Care
First CTC Funding Announcement Released in 1994
Eight CTC Sites were Funded! Some Rural, Some Urban
Created State-Wide Technical Assistance Structure
Divided state into five regions, each with a dedicated Regional Strategic Consultant (RSC) to work proactively with sites
From 1995 - 2002 PCCD funded the start-up of 127 CTC Sites throughout Pennsylvania.
Longitudinal Study
• Used Pennsylvania Youth Survey data from 2001, 2003 and 2005
• Over 231,000 student self-reports
• Stronger design because the earlier waves of data act as a control, allowing examination of within-unit change over time
• Because surveys were anonymous, examined change in school/grade cohorts across time
Longitudinal Sample
Grade 6th 8th 10th 12th Total
Non-CTC 18,116 25,766 25,094 13,726 82,702
CTC 39,988 43,230 38,466 26,996 148,680
Expected Impact (subsample of CTC)
15,917 18,158 15,525 9,721 59,321
TOTAL 58,104 68,996 63,560 40,722 231,382
Year (# schools) 2001 (91)
2003 (154) 2005 (174)
6th 4 5 6
8th 3 4 5
10th 2 3 4
12th 1 2 3
CTC vs. non-CTCRisk and Protective Factors
Coefficient P-value
Community Cohesion .0037* .008
Community Drugs/Firearms .0029* .031
School Prosocial -.0107* .000
Family Cohesion .021* .02
Family Risk -.085* .001
Antisocial Attitudes -.021* .009
Antisocial Peers -.0128* .023
CTC vs. non-CTCATOD Use
Coefficient P-value
Alcohol - Frequency of Use -.020 NS
Cigarette - Frequency of Use -.004 NS
Marijuana (past 30 day use) -.017 NS
Grades in Last Year .058* .001
Delinquency -.061* .007
a Frequency of Use statistics are based on a 2-level hierarchical model
Communities that Care
Over 2/3 of CTC sites that received PCCD start-up funding remain active and functioning.
PCCD has created an infrastructure to build and support local coalitions and to ensure they continue to be effective.
Created structure and uniformity in function for all sites assuring that all sites follow the same logic model.
PA Communities That Care
Four factors predicted sustainability
Quality of Board Functioning (Culture and Leadership)
Fidelity of CTC Implementation
Management of Changing Board Membership
Effective Sustainability Planning
Rural Areas More Likely to Succeed
Program Selection by Type
3327 28
61
0
10
20
30
40
50
60
70
Classroom-based
Community/Mentoring
FamilyPrevention
Family Treatment
Co
un
t
Classroom-based
Community/ Mentoring
Family Prevention
Family Treatment
Across Ages BBBS
Book Lending Library
BSFT
Incredible Years Buddy SystemBrookline Early Int.
Ed.FFT
Know Your Body CASASTART CLFC
MST
Lions Quest CMCA FAST
MTFC
LST Community Policing FDRP TB-CBT
MPP Core Youth After-
school GGC
OBPP Mentoring Parents As Teachers
PATHS PALS Parenting Wisely
Positive ActionParenting Wisely
PDFY
Project Alert QO PFSS
Project Northland Safe Dates PWC
RHC TND SFP
RY
Second Step
STARS
Program Classification
n=41 grantees off of funding 2 or more years
Program Sustainability
37
24
39
0
10
20
30
40
50
Not Operating Operating atReduced Level
Operating at theSame or Higher
Level
Per
cent
76%
Coalition Connection And Sustainability
67
3643
33
6457
0
10
20
30
40
50
60
70
80
None CTC Other
Per
cen
t
Not Operating
Operating at the Sameor Higher Level
Grantees off of funding 2 or more years
Summary:Sustainability 2-years Post-
funding
School-based prevention programs can be sustained!
Connection to a local prevention coalition, community and school leader support were associated with sustainability
Can we Use Existing Community Systems?
CTC Creates a New System
Can we work with Existing Community Systems to Create a “Home” for
Prevention and its Coordination in Communities?
The Cooperative Extension System!!!!Eureka!
The PROSPER Project: Promoting School-Community Partnerships
to Enhance Reslience
Richard Spoth, Cleve Redmond, Mark Greenberg, Mark Feinberg
And Many Others!!!!
PROSPER: a model for the diffusion and support of evidence-based prevention
(Promoting School-community-university Partnerships to Enhance Resilience)
PROSPER RCT
28 communities, randomly assigned to intervention or delayed wait-list control (14 each – 7 per state)
All Rural School Districts Approximately 11,000 youth across two cohorts Each community selected 1 family-focused and
1 school-based EBI from a menu Provided two years of funding for each program,
match for year three, then only team support
The Three -Tiered Partnership Model
University/State-Level TeamUniversity Researchers, Extension Program Directors
Prevention Coordinator Team–Extension Prevention Coordinators
Local Community TeamsExtension Agent, Public School Staff,
Social Service Agency Representatives, Parent/Youth Representatives
Making Use of Existing Infrastructures Extension Linked with the Public School Systems
Cooperative Extension System– Largest informal education system in the world– Over 3,150 agents in nearly every county– Science with practice orientation– Horizontal/vertical linkages for effective implementation
Public School System– Universal system reaching nearly all children– States have networks for programming support– Increasing emphasis on accountability/empirical
orientation
The Core Components: Fundamentals of PROSPER
I. A community-level PROSPER teamII. A three-tiered partnership structure
with proactive technical assistance and ties to a land-grant university
III. Utilization of evidence based programs for middle school youth and families chosen from a menu
IV. High quality program implementationV. Evaluation of program impact & process
PROSPER Partnership Goals
Positive Youth Development & Strong FamiliesPrevention of Risky Youth BehaviorsQuality administration of programsBuilding Sustainability
PreventionResearchers
ExtensionPersonnel
Public SchoolPersonnel
CommunityCitizens
Findings
Families can be effectively recruited to join these programs
PROSPER sites can implement programs with effectiveness
Significant outcomes are shown for both families and teens
Behavior How Assessed? Mean SD
Lifetime Alcohol Use
Drunk more than a few sips of alcohol? 45.1% 7%
Lifetime Cigarette Use
Smoked a cigarette? 31.9% 9%
12 Month Aggressive Behavior
Beat up someone or physically fought with someone, or thrown objects…to hurt or scare them?
32.7% 5%
12 Month Property
Destruction
Purposely damaged or destroyed property that did not belong to you?
21.3% 5%
Community 8th Grade Data
PROSPER Substance Initiation Results ─
Diverging Trajectories of Marijuana Use Through 4½ Years Past Baseline
Source: Spoth, Redmond, Greenberg, Shin, et al. (2009). Addressing addiction with community health partnerships and evidence-based intervention: Substance use outcomes 4½ years past baseline. Manuscript in preparation.
0%
5%
10%
15%
20%
25%
30%
35%
40%
Perc
ent L
ifetim
e U
se
Control
Intervention
Purpose: Improved Child and Family Outcomes
Goal 2: Sustaining Well-
Functioning Teams
Goal 1:Sustaining Growth &
Quality of Programming
Objectives
Effective External Relationships
· Strong ties with schools/aligned community organizations
· Effective communications
Effective Internal Relationships
·Strategic teams with strong participation
·Productive meetings
Evidence-based Family Program
· Delivery to increasing percentage of families
· Quality implementation
Evidence-based School Program
•Delivery to all 7th graders
•Quality implementation
StrategiesConductingEffective, Regular Meetings
Planning forRecognitions
and Rewards
Monitoring Team
Structure &Roles &
Participation
StrengtheningPartnerships with Schools/
Other Organizations
StrategicCommunication
Planning
Community/ School
Positioning
ProgramQuality
Management/Planning
Resource Generation
for Programs
PROSPER Sustainability Model
Sustainability Status
All teams and family programs sustained; 12 of 14 school programs sustained
Combination of short-term and stable funding sources
Teams have institutionalized monitoring of implementation quality/fidelity
Teams continue to use Sustainability Planning Model to guide action plans
Several teams have expanded into neighboring communities
At Year 5, Teams Sustainability Planning related to
Quality of Board Functioning (Culture and Leadership)
Orientation of New Team Members
Members see more Benefits than Costs in Participation
Illustrative Findings ─Annual Sustainability Funding
2004-5 2005-6 2006-7 2007-8$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$16,457
$7,494
Dollars Raised
In-Kind Contributions
Average per Community = $23,951
Organization
Communities
TA Systems
Program
State Plans
Programs are embedded in systems:
These systems heavily influence implementation and sustainability
Features Specific to Rural Schools and Communities — The Double-
Edge Sword
Schools are the Center of the Community Rural Schools and Communities have had growing problems but
have received much less help on how to use evidence-based models As a result there is an openness to data, ideas, and interventions
Key Leaders are known to each other There are dense social networks that can be strength or challenge!
They are substantially more stable in their roles Fewer people are necessary to co-ordinate and make decisions There is less competition among stakeholders – fewer non-
profits Cooperative Extension –in most communities is trusted and
respected.
Bottom Line: The Challenge
We will continue to see broad dissemination of a growing number of EV prevention programs thru discretionary grant programs
The programs face the challenge of maintaining implementation quality and sustainability
There is a great need to put in place school-community level systems such as CTC and PROSPER to ensure quality implementation and effective and sustainable programming
Building Systems Integration Across
Institutional StructuresDevelop Community Level Leadership across Schools and Agencies
Educate Leadership regarding Impact of Prevention and need for Cross-Institution Cooperation
Provide Training to Agency Staff, Teachers, and School Support Staff on Prevention Programming
Develop and Showcase Model Communities
“If you don’t know where you are going, you will end up
somewhere else”
Lewis Carroll
“Alice in Wonderland”
Clear Goals
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