Literature Review

Evaluation Strategies in Aboriginal Substance Abuse Programs: A Discussion

IV. Prevention Programs

Prevention strategies are included in substance abuse continuum of care for a number of reasons. Effective treatment of substance abuse is a long, complex process, with post- relapse rates in the literature varying from 35% to 85%.[Round Lake Treatment Centre . 1992. Research on Native Adolescents and Substance Abuse. The Next Generation Native Adolescent Substance Abuse Project] It is can be extremely expensive, even more so if treatment is sought out of country due to inadequate services locally or provincially. The economic costs of substance abuse in Canada are thought to be enormous, however there has been no study that has provided an overall estimate of the total costs associated with the use and abuse of all psychoactive substances in Canada. Alcohol costs have been estimated most often. These cost estimate suffer from numerous methodological and conceptual problems and may be unreliable and lack credibility.[Single, Eric.1994 Cost Considerations and Intervention Strategies. Presentation at public forum on "Managing the Social and Health Costs of Alcohol and Other Drugs." Foothills Hospital, Calgary, May 10]

Governments have widely adopted population health strategies which are designed to affect the entire population and which address the entire range of factors that determine health. Prevention is an investment which involves all determinants of health, and is not preoccupied with solely health care. In this approach, prevention strategies are targeted not only at educational materials which inform about the risks and consequences of substance abuse, but also at the environment which predisposes an individual to use and eventually become addicted to alcohol and other drugs. Cost is a major consideration in all health care services, and prevention has often been held up as a cost-effective approach to many health problems. However prevention programs have rarely been evaluated with respect to cost-effectiveness. Educational programs have been reviewed the most and have concentrated on short-term knowledge retention and attitude change, rather than long-term behavioral change.[ibid]

Types of Prevention Programs

There are a number of approaches to substance abuse prevention, from the classical education strategy to more contemporary psychosocial alternatives, such as resistance skills training and personal and social skills training. The following strategies commonly used in Canada and the United States have been detailed in Substance Abuse in Children and Adolescents, S. Schinke, G. Botvin and M. Orlandi.[Schinke, S., G. Botvin, and M. Orlandi. 1991. Substance Abuse in Children and Adolescents. Sage Publications], and are summarized briefly here. This is followed by some observations on prevention programs specifically tailored to Aboriginal people.

Information Education

This strategy is based on the concept that once individuals are educated about the adverse consequences of alcohol and drug use they will develop attitudes that are anti-drug and thus be able to make a conscious decision not to use drugs. Information education of this sort is carried out by public campaigns by advocacy organizations and government, and more locally in schools. Information programs may include fear-inducing components that graphically show the serious consequences of substance use. The many studies and reviews of traditional educational approaches to substance abuse prevention has shown that this methodology is largely ineffective. It appears that the presentation of factual knowledge will increase knowledge and change attitudes to substance abuse, however it will not reduce or prevent the actual abuse from occurring. In fact, some studies have indicated the opposite, as increasing knowledge can stimulate curiosity in teenagers.

Based on a review of Canadian and American research, it has been suggested that in order for educational programs to be effective, they must be linked to broadly based community changes in norms reinforced by public policy, and to mass media and parent-organized campaigns.[Moskowitz, J. M. 1989. "The primary prevention of alcohol programs: A critical review of the research literature" Journal of Studies on Alcohol. Vol 50, pp. 50, 54-58]

Affective Education and Alternatives

These two strategies are mainly geared to children and adolescents. They are complementary in that both attempt to steer children into non-drug environments. Affective education programs are often classroom based, and are geared to increasing self-esteem, responsible decision making, and interpersonal growth, in addition to learning current facts about alcohol and education. The alternative approach is just that - it is targeted to providing alternatives to drug-use, such as youth drop-in centres, and other recreational services. The danger in these programs is that some entertainment and vocational based programs may actually increase substance abuse, presumably due to group interaction in these environments. Overall, evaluation studies on these strategies have shown no impact on reducing substance-abuse behaviors.

Resistance Skills Training

More success has been seen in preventing substance abuse using resistance skills training which focuses on the social influences which shape perceptions of normal, acceptable and desirable behavior. This training gives students the tools to recognize, handle and avoid situations where they will experience pressure to drink or use drugs. It can include role playing, peer leaders as facilitators, and awareness of messages in alcoholic beverage advertisements. These interventions have had success in reducing the rate of smoking as well as alcohol and marijuana use.

Personal and Social Skills Training

Personal and social skills training is closely related to resistance skills training, but instead of a program-specific content, the individual is given a broad range of skills for coping with life. Typical components to these programs include problem solving skills, general cognitive skills for resisting peer pressure or advertisements, skills for increasing self-control and self esteem, general assertiveness skills, and interpersonal skills.

This prevention approach has shown significant behavioral effects, primarily in reducing experimental use of tobacco. There is also some evidence that it may also reduce the level of regular use.

Community-Based Approaches

There are few examples of community approaches to substance abuse prevention in the non- Aboriginal environment, except for parents' movements, such as MADD (Mothers Against Drunk Driving). In general, these strategies include parents, schools, and community-based organizations, and focus on direct training of youth in the acquisition of drug resistance skills and the training of teachers, parents and other community members as program implementers. One community initiative in the United States - Communities That Care - is described below.

Early Intervention Strategies

Early intervention strategies are directed to identifying people who are using alcohol or drugs and may be experiencing early problems. The objective is to help these people before they reach a chronic or habitual stage. In addition to identification by health care professionals who may use standardized tests to evaluate high risk individuals, other early intervention strategies include programs for impaired drivers and wellness or employee assistance programs in the workplace. There has been some success in early intervention strategies, such as reduced drinking or abstinence in "problem" drinkers who are not yet alcohol dependent.[Socio-Tech Consulting Services. 1994. Addictions Intervention Needs of First Nations: 1994 and Beyond. Prepared for the National Native Alcohol and Drug Abuse Program (NNADAP), Saskatchewan Region.]

Prevention Strategies for Aboriginal People

Programs targeted specifically to substance use are the formal mechanism to reduce this problem in society. In the Aboriginal context, however, it is important to acknowledge that one of the best prevention programs is directed at improving the dismal socio-economic conditions that face most Aboriginal people, whether in reserve, rural or urban locations. The link between socio-economic status and substance abuse has been established. For example, the Saskatchewan Alcohol and Drug Commission in a review of 1991 data showed that their clients experienced much higher unemployment levels and lower educational levels compared to the general Saskatchewan population.[ibid]

Control policies targeted at alcohol consumption, such as government regulations on the minimum drinking age, and price increases can reduce alcohol-related fatalities or alcohol consumption. However, on First Nations reserves, 'dry reserve' policies have largely not been effective. This has been linked to a lack of enforcement by Band Council resolution or a community mediation/policing service.[ibid]

Prevention programs for Aboriginal people are not highly differentiated from treatment programs. This could be a reflection of the immediacy of need now in treating addicted persons. Since effective substance abuse programs appear to be closely linked with support from the community and role modeling by community leaders, the changing societal norms in these communities may have an unevaluated but important prevention role.

Examples of Prevention Programs

In Aboriginal communities, prevention strategies are most commonly funded by the NNADAP program. The primary role of NNADAP workers in communities is alcohol and drug education. Past reviews have criticized NNADAP prevention programs as inadequate. This has been ascribed to a focus on treatment, counseling and aftercare for persons identified as substance abusers, in the activities of the NNADAP staff.

1. Round Lake Treatment Centre
   Early Intervention Strategy
   
   The Round Lake Treatment Centre implemented a demonstration project on a non-residential solve nt abuse community intervention in 1994.[Round Lake Treatment Centre. 1994. A Demonstration Project to Test a Community Based Solvent Abuse Intervention Model. The Next Generation Solvent Abuse Community Intervention and Resource Project] Four communities were involved in the project and have provided varying perspectives to the initial three month pilot. Only one community took full advantage of the community resources, and internalized a strong sense of ownership, commitment and empowerment to address solvent abuse among the youth. This was facilitated by close work with community agencies, elders, youth and families to undertake community change and ongoing community action.
   
   In the other three communities, the attention brought to solvent abuse was beneficial, as individuals acquired new skills and made visible commitments to help the community address solvent abuse. Community intervention plans were begun, and youth were identified and referred out to solvent abuse residential programs. However, the effectiveness of the demonstration project in these three communities was limited by a lack of a serious, time-intensive commitment in two, and a constant crisis of youth suicide in the third. Overall, an evaluation of the demonstration project showed 10 key elements critical to the successful implementation of this type of program:
   
   
   1. A clear set of principles, plan and strategy.
   2. Visible commitment by Chief and Council through word and action
   3. A qualified full time community liaison worker
   4. A specialist team which is skilled and cohesive
   5. Clinical and project management support
   6. Availability of external resources, particularly treatment resources for solvent abusers and their families.
   7. A realistic time frame for the project (up to one year)
   8. proficiency in Aboriginal language by the Specialist team members.
   9. A holistic community-based training program (including team building) for the community intervention team, Chief and Council, police, medical personnel, and other health personnel.
   10. An internal and external agency coalition to collaboratively address solvent abuse and other related health problems.
       
       
2. Communities That Care
   Community-Based Prevention
   
   Research findings have supported comprehensive community-wide interventions as one of the most promising approaches to adolescent drug abuse prevention. The Communities That Care drug reduction strategy developed in the United States has been held up as a model intervention in a conference of social scientists and evaluators.[Peterson, P.L., J.D. Hawkins, and R.F. Catalano. 1992. "Evaluating comprehensive community drug risk reduction interactions: Design challenges and recommendations." Evaluation Review. Vol 16, pp. 579-602] The Communities That Care strategy uses community mobilization processes to reduce risk factors and increase protective factors against drug abuse. Mobilization consists of four phases:
   
   
   1. community key leader recruitment and orientation
   2. community advisory board formation
   3. risk and resource assessment by the community board to identify priority risk factors
   4. action planning and implementation of family, school and community interventions which have been developed by the community and which reduce risk factors and enhance protective factors.
   
   
   In the strategy, a minimum of three interventions are developed for each of three domains: school, family and community. The following general prevention principles form the core of the Communities That Care strategy:
   
   
   • interventions should focus on known risk and protective factors.
   • interventions should target risk and protective factors which are appropriate for different levels of development.
   • prevention of drug abuse should start early, including major components that are delivered before drug use initiation occurs.
   • interventions should reach people at high risk.
   • interventions must address multiple risk factors across multiple domains - individual, family, school, peer group and community.