Program
Background
The Midwestern Prevention Project
(MPP) is a comprehensive community-based drug abuse
intervention program that uses school, mass media,
parent, community organization, and health policy
programming to reduce or prevent gateway drug use
(i.e., tobacco, alcohol, marijuana) and other drug
use by adolescents and, secondarily, drug use by their
parents and other community residents. The term "gateway"
refers to the predictive relationship of tobacco,
alcohol, and marijuana to the use of more illicit
substances later in life.
Over the last 15 years, several
primary prevention programs have been implemented
using single avenues, or channels, for program delivery.
Single channel programs are implemented entirely within
one setting (e.g., a school), as opposed to multiple
channel programs, such as the MPP, which integrate
a school-based program with a parent and community
program and a mass media program. When more channels
or opportunities for disseminating a prevention message
are used, there is a greater likelihood that the behavior
in the prevention message will be adopted.
With few exceptions, researchers, policy makers,
and drug prevention program planners have recently
questioned whether single channel programs are sufficient
to effect significant and lasting changes in adolescent
drug use behavior. The effects of most large-scale,
school-based programs have been minimal to moderate,
short-lived or delayed. Explanations for this limited
success have included program brevity as a result
of competition with regular academic subject areas
for teaching time and resources, the lack of integration
of school-based programs with community programs,
and conflicting messages from environmental influences
outside the school which fail to reinforce nondrug
use norms. Additionally, school-based programs may
not reach those youth who are at highest risk for
drug abuse, including school dropouts, chronic absentees,
runaways, and gang members.
The limitations of school-based programs argue for
more comprehensive programs that address the multiple
environmental influences to use drugs, which are generally
beyond the scope, budget, and influence of school-based
programs. By using multiple program channels or opportunities
for prevention message (program) delivery (including
schools, parents, community organizations, mass media,
and policy), the skills which are learned initially
in the school program are reinforced by a consistent
community social norm for nondrug use. Greater message
consistency is likely to lead to more rapid formulation
of nondrug use attitudes, intentions, and behavior.
Other advantages include a larger pool of prevention
activities and resources to draw on in the community
than a school with its limited resources, increased
community support of prevention programming as community
understanding of drug abuse and prevention programming
increases, and the ability to reach a larger target
audience. The community, or local government, is also
the most appropriate channel for policy-setting and
institutionalizing drug prevention in the community.
The MPP is an intervention with multiple components
(i.e., channels) targeted at the entire community.
Community-based prevention efforts are a fairly recent
phenomenon, proliferating since the mid-1980s and
yielding evaluation results only since the early 1990s.
Only one school-based prevention program has shown
sustained effects on adolescent substance use through
the end of high school, and achieving this effect
required three successive years of continued intervention.
Community-based programs, with school programs as
a central component, may yield stronger, longer-lasting
effects on substance abuse than school programs alone
or other single-channel programs, and for some substances,
larger effects.
Arguments for a Community-Based
Prevention Approach:
- Counteract multiple social influences on adolescent
drug use with program components aimed at each influence
(school, parent, community, policy, mass media)
- Reinforce social norms for nonuse across multiple
segments of the community
- Provide more sustained program exposure than is
available from most school programs
Theoretical Rationale/Conceptual
Framework
The MPP is based on an integrative theoretical perspective
that views behavior as the result of a set of complex
interactions between person, situation, and environment
level variables in a community. Within this framework,
changes (improvements) in individual skills, as well
as communications and policy interventions aimed at
community agencies and systems are essential to effect
any lasting changes in behavior patterns. The
person x situation x environment theoretical
perspective was used to develop the content of MPP
program components (Figure 1).
Person x Situation
x Environment Theoretical Perspective
Person level variables
were derived from social psychological theories
of individual behavior change, assuming a progression
of knowledge > attitude > behavior change. The
MPP program component that best represents this theoretical
level involves the skills training programs which
focus on teaching students about peer and other social
pressures and developing personal decision-making
skills to resist these pressures, and changing appraisal
of drug use.
Situation level variables
were derived from social psychological, social
support, and networking models of interpersonal and
group behavior change. The MPP integrates this theoretical
level into its programming through the use of interpersonal,
group, and support training programs (e.g., parent
training programs which focus on parent-child communication
about drug use prevention, parent leader and school
principal ability to communicate and support each
other in drug use prevention in schools, and community
and local government leader ability to organize and
network more effectively to promote resource sharing
among community agencies). Situation level variables
concern interpersonal and group interactions. Skills
taught include resistance to peer group pressure and
positive communication with parents and peers about
prevention.
Environment level
variables were derived from organizational
development and communication theories, and public
health and social action models of systems change.
At the environmental level, interventions tend to
consist of events focused on prevention, message dissemination,
raising funds to institutionalize prevention programs,
and community policy changes rather than program delivery.
The MPP addresses environment level variables by including
mass media, community organization, and policy change
strategies to help institutionalize drug abuse prevention
in the community.
Addressing Both Demand and
Supply Reduction
Most drug use interventions have focused on either
demand reduction or supply reduction, but not both.
Demand reduction strategies affect the behavior of
users (on the demand side), and supply reduction strategies
affect the behavior of distributors (on the supply
side). Prevention programs are primarily demand reduction
strategies; that is, if one teaches youth to avoid
drugs, the demand for drugs will be reduced. Demand
reduction programs teach resistance and avoidance
skills and increase perceptions of nonuse norms, prevention
messages aimed at the undesirability of drug use,
and offer cessation programs in conjunction with prevention
efforts. Educators have usually been involved in demand
reduction, while law enforcement personnel have typically
been involved in supply reduction. Supply reduction
approaches to drug abuse are aimed mainly at controlling
or reducing access to drugs. Local community supply
reduction strategies have included restricted-access
policies, such as drug-free zones and bans on use
in public places, restriction or monitoring of merchant
licensing, training and monitoring vendors to refuse
sales to minors, and removal or monitoring of cigarette
vending machines.
Research on some supply reduction strategies, such
as raising the drinking age, limiting access to alcohol
in public places, and DUI monitoring, have shown significant
reductions in alcohol consumption and sales, DUI behavior,
and alcohol and drug-related accidents for short-term
periods for up to two years. However, there is no
evidence that policy change (supply reduction) alone
promotes the development or implementation of prevention
programs in the community. On the other hand, demand
reduction strategies can produce long-term decreases
in youth tobacco use as well as gradual policy change.
However, it may be an insufficient focus for programs
aimed at parents and community groups. Increasingly,
both strategies are being incorporated into prevention
programs by schools and communities.
The MPP integrates both demand and supply reduction
strategies by combining prevention programming (i.e.,
school-based drug resistance skills training) with
local school and community policy change (aimed at
limiting youth access to drugs). These policy changes
are implemented by parents, school administrators
and community leaders as part of the parent and community
organization programs. One study has shown that schools
with prevention-oriented smoking and drug policies
mandating drug-free zones, support for students with
drug use problems, and prevention programming as a
regular part of the schools' educational curricula
have lower smoking prevalence rates among students
than do schools with more punishment or supply reduction
policies.
Brief Description of Intervention
The MPP is a comprehensive population-based drug abuse
intervention program which consists of five program
components introduced in sequence (at the rate of
six months to one year apart over a five year period)
to communities: school, parent, community organization,
and health policy, with utilization of mass media
throughout all the sequenced components. The program
is introduced first in the schools, where adolescents
are most easily reached. The success of school program
implementation is disseminated to parents, who then
participate in an extended prevention program at home
with their adolescents, following the school program.
The school and parent programs—with school and
home as program channels—would follow with related
programs and channels. For example, mass media prevention
programs could be targeted to adolescents and their
parents who had participated in the school and parent
programs, and simultaneously reach family members
and other interested community residents who would
constitute a modeling influence on adolescents.
Collectively, the components focus on promoting drug
use resistance and counteraction skills by adolescents
(direct skills training); prevention practices and
support of adolescent prevention practices by parents
and other adults, including teachers, expected to
serve as role models for adolescents (indirect skills
training); and promotion and support of nondrug use
social norms and expectations in the community (environmental
support). The five components are briefly explained
below.
Mass Media
The mass media component, which is initiated with
the school program during the first year and continues
for almost five years, consists of approximately 31
television, radio, and print broadcasts per year,
ranging from one-hour talk shows to 15-second commercials
and public service announcements. These broadcasts,
which use simple messages, are intended to introduce
and explain to the community the school-based program
and each new program component as it is added. The
messages delivered by each program component, especially
the school and parent programs, are reinforced by
broadcasting to the larger community of residents
who provide a modeling influence on adolescents.
School Program
The school program, which is the central program channel,
is initiated in grade six or seven (i.e., depending
on the local school district, the transition year
into middle or junior high school), delivered by trained
teachers, and facilitated by peer leaders nominated
by the class and trained by the teacher. The program
includes 10-13 classroom sessions focused upon increasing
skills to resist and counteract pressures to use drugs,
and to change the social climate of the school to
accept a nondrug use norm. The second year (grade
seven or eight) includes a five-session booster program
to reinforce the previous year's message, and in the
subsequent high school years peer counseling and support
activities are provided.
Parent Program
The focus of this component, initiated in year two
and lasting through year three, is to develop family
support and modeling for a nondrug use norm within
the family and in the school neighborhood and includes
parent education and organization throughout middle
school. This is accomplished by the creation of a
group consisting of the principal, four to six parents,
and two student peer leaders from each school who
meet throughout the school year to: (1) refine school
policy to institutionalize prevention programming
in the school; (2) help provide a drug-free environment
by monitoring the school grounds and surrounding neighborhood;
and (3) plan and implement parent skills training
twice a year for all parents, focusing on parent-child
communication and prevention support skills.
Community Organization
During the third year and continuing through year
five, community and government leaders are enlisted
and trained to form a community organization to plan
and implement drug abuse prevention services and activities
that complement the other program components. The
community organization component involves agency networking
and facilitating referrals for services across agencies.
Health Policy
During the fourth and fifth years, health policy is
implemented by a government subcommittee which is
formed from local community and government leaders
from the community organization component. The role
of this subcommittee is to actively implement policy
change initiatives that reduce demand and limit supply
(e.g., local ordinances restricting cigarette smoking
in public settings, increased alcohol pricing and
limiting availability, drug policies mandating drug-free
zones, financial support for prevention programming,
and law enforcement efforts).
Evidence of Program Effectiveness
The MPP has resulted in net reductions of up to 40
percent in daily smoking, similar reductions in marijuana
use, and smaller reductions in alcohol use, which
have been maintained up to grade 12. By the end of
the fourth year in Kansas City (ninth/tenth grade),
cocaine and crack use was less in intervention schools.
By early adulthood (two years after high school),
program youth also demonstrated reductions in the
need for drug abuse treatment. Significant effects
were found even when the data were adjusted (or stratified)
for race, grade, gender, urbanicity, socioeconomic
status, and risk.
The MPP has also resulted in decreasing parent alcohol
and marijuana use, increasing positive parent-child
communications about drug use prevention, and facilitating
development of prevention programs, activities, and
services among community leaders. Policy changes associated
with MPP have included institutionalization of the
school program, establishment of youth drug abuse
treatment beds, and cooperation from vendors to refuse
tobacco and alcohol sales to minors.
The demonstration of program effects on secondary
as well as primary outcomes supports the hypothesis
that the MPP is operating as a comprehensive, community-wide
intervention.
