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Module 3 - Preventing Alcohol Abuse and Dependence

PARTICIPANT HANDOUT

Introduction

This module focuses on the role that social workers play in the prevention of alcohol abuse and dependence. An often-told anecdote points out the distinction between, and the interconnectedness of, treatment and prevention efforts:

Two social workers are standing by a roaring river during the spring runoff. They notice a person caught up in the current and being pulled rapidly downstream. They respond by pulling the person to shore. However, before they have completed this effort, another person comes downstream. While they are busy with this person, two more come along. One of the social workers responds by trying to pull these people out of the river, too. The other social worker pauses and, after thinking for a moment, starts walking upstream. The first social worker yells, "Where are you going? We have a crisis to attend to here!" The other social worker says, "I'm going upstream to find out how they got into the river in the first place" (McKinlay, 1997, pp. 519-533; Minuchin, Colapinto, & Minuchin, 1998, p. 4.)

The persons in the river clearly needed immediate attention (treatment). However, if they had never fallen into the river, or if others could be stopped from falling in (prevention), there would be less need for the treatment resources. While real life is more complex than portrayed in this story, the point is that treatment and prevention go hand in hand.

Learning Objectives

This module explores several frameworks for social work prevention and discusses their application to the prevention of alcohol use disorders. Specific strategies that have been implemented and empirically tested are described.

By the end of this module, learners should be able to:

A. Recognize and understand generic frameworks for the development and analysis of social work prevention efforts
B. Develop an analysis of relevant vulnerability/resilience factors for planning interventions to prevent alcohol use disorders
C. Develop an analysis of relevant risk/protective factors for planning interventions to prevent alcohol use disorders
D. Become familiar with a set of empirically-based alcohol use disorder prevention programs

What is "Prevention"?

Barker (1999, p. 375) refers to prevention as:
"Actions taken by social workers and others to minimize or eliminate those social, psychological, or other conditions known to contribute to physical or emotional illnesses…. Prevention includes establishing those conditions in society that enhance the opportunities for individuals, families and communities to achieve positive fulfillment."

 

In a similar vein, Bloom (1996, p. 2) states that prevention is:
"Coordinated actions seeking to prevent predictable problems, to protect existing states of health and healthy functioning and to promote desired potentialities in individuals and groups in their physical and sociocultural settings over time."

Clearly these notions of prevention fit well with the basic values of social work as spelled out in the National Association of Social Workers Code of Ethics. Namely, that social work seeks to enhance human well-being, helps to meet the basic needs of all people, pays particular attention to the needs and empowerment of people who are vulnerable, promotes positive social change, and demonstrates sensitivity to cultural diversity (Mayden and Nievies, 2000). In other words, there is a natural fit within social work for the kinds of prevention efforts addressed in this module.

Prevention involves:
- focusing on the conditions that contribute to problems
- taking action before the problems develop or become serious

Prevention Frameworks

Current Prevention
Intervention Classifications

  • Universal
  • Selective
  • Indicated

Earlier Prevention
Intervention Classifications

  • Primary
  • Secondary
  • Tertiary

Gordon (1987) proposed a preventive intervention classification system based on the population groups to whom prevention interventions are directed and for whom they are thought to be most optimal.

Universal prevention efforts are those that are applied to everybody in an eligible population. In other words, universal efforts are targeted to the general public or the general population. The focus is on persons who are not considered to be at higher risk than others and the benefits outweigh the cost and risk for everyone.

Selective prevention efforts are focused on individuals or subgroups of the population whose risk of developing problems of alcohol abuse or dependence is above average. The subgroups may be distinguished by characteristics such as age, gender, family history, or economic status. Subgroups may also be identified by past experience or behavior, such as individuals who have been sexually or physically abused. While risk levels are higher, not all individuals within the subgroups will experience alcohol use problems.

Indicated prevention efforts apply to persons who exhibit specific risk factors or conditions that individually identify them as being at risk for the development of alcohol abuse (e.g., early experimentation).

The universal-selective-indicated framework is currently the most common mental health prevention model and will be applied in this module. An earlier classification system developed by the Commission on Chronic Illness (1957) served for many years as a common framework for targeting prevention efforts. While this public health framework is no longer popular in planning preventive interventions in social work practice, it is important that social workers become familiar with it since it is used in much of the fundamental prevention literature.

The classification system consists of three types of prevention: primary, secondary, and tertiary. As characterized by Last (1983), primary prevention involves the promotion of health and elimination of alcohol abuse and its consequences through community-wide efforts, such as improving knowledge, altering the environment, and changing the social structure, norms, and values systems. Secondary prevention uses approaches available to individuals and populations for early detection within high-risk groups and prompt and effective intervention to correct or minimize alcohol abuse in the earliest years of onset. Tertiary prevention consists of measures taken to reduce existing impairments and disabilities and to minimize suffering caused by alcohol abuse.

On the surface, these two classification systems appear to be almost the same. Indeed, the practical overlap between universal and primary prevention, as well as selective and secondary prevention, is great. Primary prevention is often directed at universal populations and secondary prevention efforts are generally targeted to selective "at risk" groups. However, there are important distinctions in comparing indicated prevention with tertiary prevention. Indicated prevention intervenes with individuals who have a high probability of the development of the problem, but prior to the problem's manifestation. Tertiary prevention addresses a problem after it has developed and is essentially a form of treatment that also involves the prevention of worsening conditions, as well as the emergence of secondary problems. Indicated prevention is based on the probability of a problem developing and thus benefits may come only in the form of delaying or eliminating a future problem, whereas tertiary prevention provides immediate traceable benefits (Mrazek and Haggerty, 1994).

Vulnerability, Resilience, Risk, and Protective Factors

Regardless of the classification system used, the overall aim of prevention interventions is to reduce the occurrence of new cases. This is most often accomplished by decreasing risk and vulnerability factors and/or increasing protective and resilience factors (Begun, 1993). Vulnerability and resilience factors are intrinsic to the individual through biology (e.g., genetics, constitution, hormonal balances), past experiences and learning (i.e., personal history), behaviors, and individual traits (e.g., personality and temperament). Risk and protective factors refer to those social and environmental characteristics that are extrinsic to the individual and form a context for their lives (Begun, 1999).

Vulnerability and Risk Factors
- Biology
- Past experiences
- Behaviors
- Individual traits

A central idea in this approach is that the more risk and vulnerability factors a person experiences, the more likely it is that he or she will experience substance abuse problems (Newcomb and Felix-Ortiz, 1992). However, it is important to note that this is a probabilistic statement. In other words, not all individuals growing up or living in an environment with many risk factors develop the problem. Many persons growing up in a high-risk environment emerge relatively problem free, as do many individuals who seem highly vulnerable. Some researchers attribute this to the presence of protective factors (Hawkins, Catalano, & Miller, 1992; Mrazek and Haggerty, 1994). In other words, there may be positive characteristics and circumstances in a person's life that reduce or prevent problems from developing. A useful framework for conceptualizing the probability of the problem appearing within a population is illustrated in Figure 1 where the interaction of the two continua (vulnerability-resilience and risk-protection) is presented.

Figure 1. Interaction of Vulnerability/Risk Continua.


Low Vulnerability/High Resilience <----------------------------------> High Vulnerability/Low Resilience

Low Risk/ High Protection <------------------------------------>High Risk/Low Protection

 

VULNERABILITY

Low

High

RISK
Low

1. Low Probability

2. Moderate Probability
High

3. Moderate Probability

4. High Probability

Hawkins and colleagues (1992), after conducting a comprehensive literature review, defined two categories related to risk of developing problems, including substance abuse. The first category, individual and interpersonal risk factors, includes such things as sensation seeking, poor impulse control, family behavior and attitudes that promote alcohol misuse, inconsistent parental discipline, family conflict, low family bonding, academic failure, low commitment to school, rebelliousness, and early onset of alcohol use. The second category, contextual and other environmental risk factors, includes such things as availability of substances, economic deprivation, poor housing, neighborhood disorganization, and laws/norms favorable towards alcohol consumption.

Prevention Strategies

General prevention goals can be derived from the results of an analysis such as that depicted in Figure 1. One goal is to "move" the group of individuals who are in the highest probability group (high on vulnerability and living in high risk contexts) into lower probability groups.

This can be accomplished by:

  • increasing the protective factors
  • decreasing the risk factors
  • increasing resilience
  • decreasing vulnerability

For problems with the complexity of alcohol use disorders, it is likely that more than one of these strategies will need to be implemented in order to have a significant preventive impact. Similarly, the prevention goal with individuals in the two moderate probability groups (either high vulnerability but in a low risk environment or those in high risk environments but having low vulnerability) would be twofold. The first is to preserve the protective and resilience factors that are present, thereby preventing a "move" into the highest probability group. The second is to intervene to reduce the category of factors that is preventing them from being in the safest, low probability group. Clearly, relatively little needs to be done for the low probability population aside from ensuring that their protective and resilience factors are maintained and that no new vulnerabilities or environmental risks are introduced.

Table 1 separates alcohol disorders risk and protective factors into six domains (SAMHSA, 2001). This functional framework goes beyond compiling a long list of factors to considering how social workers can organize prevention efforts to address groups of similar factors.

Table 1: Domains and Associated Risk and Protective Factors
Domain
Risk / Protective Factors
Individual

biological and psychological dispositions, attitudes, values, knowledge, skills, problem behaviors

Family

function, management, bonding

Peer

norms, activities, bonding

School

bonding, climate, policy, performance

Community

bonding norms, resources, awareness & mobilization, policy

Society/Environmental

norms, policy / sanctions

A useful way to think about prevention is to spell out some of the approaches or principles within each of the domains in Table 1. These types of efforts are typically made in prevention programs and can act as a guide for social workers when thinking about prevention efforts to target alcohol use disorders. Reflected in these principles is the idea that effective prevention strategies should be based on identifying risk factors that predispose persons to substance abuse, and then either reducing or eliminating those factors. In addition, protective factors should be identified and then strengthened.

Individual Domain

  • Build social and personal skills
  • Design culturally sensitive interventions
  • Provide culturally competent, positive alternatives to help youth in high-risk environments to develop personal and social skills in a natural and effective way
  • Recognize that relationships exist between substance use and a variety of other adolescent health and mental health problems

Family Domain

  • Target the entire family system
  • Help develop bonds among parents in programs; provide meals, transportation, and small gifts; sponsor family outings
  • Ensure cultural sensitivity
  • Help families respond to cultural and racial discrimination, and inequity issues
  • Develop age and culturally appropriate parenting skills
  • Emphasize family bonding
  • Offer sessions where parents and youth learn and practice new skills
  • Train parents to both listen and interact appropriately and effectively
  • Train parents to use positive and consistent discipline techniques
  • Promote new skills in family communication through interactive techniques

Peer Domain

  • Structure alternative activities and supervise alternative events
  • Incorporate social and personal skills-building opportunities
  • Design intensive alternative programs with a variety of approaches and a substantial time commitment
  • Communicate peer norms against the use of alcohol and illicit drugs
  • Involve youth in the development of alternative programs
  • Involve youth in peer-led interventions or interventions with peer components
  • Counter the effects of deviant norms and behaviors by creating opportunities for youth with behavior problems to interact with other non-problematic youth

School Domain

  • Correct misconceptions about the prevalence of use in conjunction with other educational approaches
  • Give students opportunities to practice new skills through interactive approaches
  • Help youth retain skills through booster sessions
  • Involve parents in school-based approaches
  • Communicate a non-ambiguous commitment to substance abuse prevention in school policies
  • Control the environment around schools and other areas where youth gather

Community Domain

  • Develop integrated, comprehensive prevention strategies rather than one-time community-based events
  • Increase positive attitudes through community service
  • Emphasize to employers the cost of substance abuse and the benefits of prevention
  • Include representatives from every organization that plays a role in fulfilling coalition objectives
  • Retain active coalition members by providing meaningful rewards
  • Define specific goals and assign specific responsibility for their achievement to subcommittees and task forces
  • Organize community alcohol-free events
  • Support a large number and wide continuum of prevention activities
  • Organize at the neighborhood level

Society/Environmental Domain

  • Develop community awareness and culturally competent media efforts
  • Use mass media appropriately
  • Set objectives for each media message delivered and measure the impact
  • Broadcast messages frequently over an extended period of time
  • Broadcast messages through multiple channels when the target audience is likely to be viewing or listening
  • Combine beverage server training with law enforcement
  • Increase beverage servers' legal liability
  • Increase the price of alcohol through excise taxes
  • Limit the location and density of retail alcohol outlets
  • Enforce minimum purchase age laws (e.g., use undercover buying operations)
  • Use community groups to provide positive and negative feedback to merchants
  • Employ more frequent enforcement operations
  • Enact deterrence laws and policies for impaired driving (including watercraft)
  • Combine sobriety checkpoints with positive passive breath sensors
  • Revoke licenses for impaired driving
  • Immobilize or impound the vehicles of those convicted of impaired driving
  • Target underage drivers with impaired-driving policies

Moving From Strategies to Programs

CSAP (1995) provides a guide for program development and implementation that may be useful for social workers involved in prevention work. Some of the key steps are:

(1)
Define the problem in such a way that you can target the underlying contributing factors. Once a problem has been identified, it is important to gain an empirically-based understanding of possible explanations. For example, adolescent alcohol use may be related to poverty, poor family management, peer pressure, poor adult role models, poor school performance, lack of bonding with positive social institutions, or lack of social skills. A needs assessment that includes an exploration of possible factors that contribute to the problem of alcohol abuse and a thorough literature review related to the identified problem should be conducted. The needs assessment and literature review help to narrow the range of possible points of intervention.

(2) Consult the literature to see what interventions have been used, the process for carrying them out, and what outcomes to expect. This critical step in the process of starting a prevention program prevents expending time and resources "reinventing the wheel." In addition to local and university libraries, there are significant Internet sources such as:

(3) Assess the available strengths, weaknesses, potential barriers, and resources. The idea here is to evaluate the feasibility of carrying out the program. For example, a program must be supported by agency policies, be fundable, and have access to participants. Some of the information for this analysis may have been gathered as part of the needs assessment.

(4) Develop and implement the program. This involves tasks such as obtaining or developing program materials, marketing the program, recruiting participants, hiring staff, etc.

(5) Evaluate the intervention. As social workers we have an ethical obligation to make sure that our practices are effective. When running a prevention program, we must continually monitor to see if the program meets the established goals and objectives and if this is accomplished in the most efficacious manner. It is important to establish short- and long-term outcome goals and process measures. If trained staff members are not available to assist with the evaluation, contracting with program evaluation firms or consultants is a good idea.

Examples of Prevention Programs

One way of pulling all of these strategies together is to provide brief descriptions of some prevention programs from the literature. These programs are examples of universal and selective approaches. However, it should be noted that the classification of some programs as selective was somewhat arbitrary. If the targets of the interventions were defined as being at high-risk for developing alcohol abuse, then the programs would have been using an indicated prevention approach. Since prevention efforts concentrate on taking action before the specified problem develops, much of the work in prevention does target youth. The first three programs fit this model. However, there is an increasing focus on prevention strategies that go beyond skill-building youth-oriented approaches. These broader community approaches are represented by the fourth and fifth program descriptions.

1. Life Skills Training
The first example represents a universal approach to prevention, since it typically targeted all children within a school system, rather than only those children who could be identified as being at high-risk. The program utilized Life Skills Training (LST), a cognitive behavioral, psychoeducational approach (Botvin, Schinke, Epstein, & Diaz, 1984). Students were taught how to resist social influences to smoke, drink, or use drugs. These resistance or peer refusal skills were taught within the context of a broader program designed to enhance general personal and social skills. There was a focus on knowledge and skills needed by youth to cope with the developmental influences during adolescence, including such issues as problem solving, decision-making, self-awareness, effective communication, assertiveness, and stress reduction. The LST program was developed for middle or junior high school students. It consisted of 15 classes that could be implemented in the student's first year of middle school (usually the 6th grade) or the first year of junior high (usually the 7th grade). The program included five major components, which consisted of two to six lessons that were taught in sequence. The LST program also included a booster curriculum consisting of 10 classes during the students' second year of middle or junior high, and 5 classes during the third year.

Botvin, Baker, Dusenbury, Tortu, and Botvin (1990) reported on a three-year study of the LST program involving over 4,000 students attending 56 schools in New York State. Students who received at least 60% of the prevention program (N=3,684) participated in an analysis of program effectiveness. Significant prevention effects were found for cigarette smoking, marijuana use, and excessive alcohol use. Prevention effects were also found for normative expectations and knowledge concerning substance use, interpersonal skills, and communication skills. Similar results have been obtained across a wide variety of settings and populations by Botvin and his colleagues (for example see: Botvin et al., 1994; Botvin, Baker, Dusenbury, Botvin, and Diaz,1995).

2. Seventh Generation Program
A selective prevention program that incorporated cultural components was provided by Moran (1998). This study was designed to develop and evaluate a culturally appropriate alcohol prevention program focused on urban Indian 4th-7th graders in Denver. The conceptualization and structure of the program relied on the prevention research literature, and also on information gathered through focus groups with members of the local Indian community. The program used the following literature based approaches: (a) correcting inaccurate stereotypes that over-emphasize the amount of alcohol use; (b) enhancing personal and cultural values that are in conflict with alcohol use; (c) enhancing self-esteem; (d) teaching a structured way for making good decisions; (e) learning and practicing skills to resist peer pressure; and (f) making a personal commitment to not use alcohol. In other words, it utilized a life skills approach.

Ideas expressed in the focus groups resulted in a plan to incorporate American Indian culture in a manner that might be meaningful to urban Indians. Over the course of several meetings, an agreement emerged that a set of core values transcended tribal differences. From a list of over 20 values, the participants narrowed the list to seven: Harmony, Respect, Generosity, Courage, Wisdom, Humility, and Honesty. These values are reflected in American Indian cultural concepts such as the Medicine Wheel of the Northern Plains (Figure 1) or the Navajo statement, Walk in Beauty. Thus, rather than utilizing cultural artifacts such as teaching children Indian arts and crafts, the Seventh Generation Program was developed in a manner that focused on cultural values. The program consisted of a 13-week intervention followed six months later by a five-week booster. The after-school program was divided into seven main topical areas (such as enhancing Indian identity, decision making, making a meaningful commitment) and each of the two-hour sessions focused on the particular topic for that week in addition to several of the seven core values.

Figure 1: Medicine Wheels

 An Image of Medicine  Wheels d

Figure 2:

The Diné People (Navajo Nation)

The Navajo have a phrase, "walk in beauty", which means to be in harmony with nature.

Across three intervention periods, 257 fourth through seventh grade American Indian youth participated in the intervention. A total of 121 served as the comparison group. Pretest, posttest, and one-year follow-up data were collected on several mediator variables and on alcohol use (Moran & Reaman, 2002). The intervention and comparison groups were not statistically different at either pretest or posttest. At one year, however, the intervention group scored more favorably on measures of: (a) structured decision making, (b) less positive beliefs about the impact of alcohol use, (c) less depression, (d) higher levels of school bonding, (e) positive self concept, and (f) higher levels of perceived social support. In addition, only 5.6% of the intervention group, compared to 19.7% of the comparison group, reported drinking in the past 30 days.

3. Project Northland
Project Northland (Perry, Williams, Veblen-Mortenson, Toomey, Komro, & Anstine, et al., 1996) is an example of a selective prevention approach that moved beyond work with individual students to include the larger community. This project focused on 20 high-risk communities in northern Minnesota: 10 intervention communities and 10 comparison communities. The Project targeted students in grades six through eight but also included parents and the larger community. Separate curricula were developed for each grade level and included classroom sessions focused on social resistance skills training. Homework assignments with parent involvement were also included. Other components included the development of peer-directed, alcohol-free activities outside of school, informational material to be taken home, newsletters to parents, and community organization to form task forces for the development of policies related to underage drinking. Examples of these types of activities included: (1) student interviews with various community members to gather information to develop model alcohol policies, (2) presentation of the policies in simulated town meetings, and (3) student-produced anti-alcohol plays that were presented to parents. A goal of the program was to move the center of attention away from the individual student to interaction with family, peers, and the larger community. After three years in the program, students who received the intervention had statistically significant reductions in the onset and prevalence of drinking (Williams and Perry, 1998). The overall finding was positive effects on those who had not yet begun drinking at the start of the program, but little or no impact on students who had already started drinking prior to the program (NIAAA, 2000).

4. Communities Mobilizing for Change on Alcoholism
One example of a broader prevention focus is the Communities Mobilizing for Change on Alcoholism (CMCA) program that sought to reduce access to alcohol for 15 to 20 year olds (Wagenaar, Murray, Wolfson, & Forster, 1994). Although the goal was to reduce drinking and drinking-related problems among older adolescents, youth were not the direct intervention target. The target of intervention was the communities. Since this effort sought to have an impact on all youth rather than only those with drinking-related problems, it was a universal prevention program. The project focused on changing community level policies and enforcement efforts regarding youth access to alcohol. Seven pairs of matched communities in Minnesota and Wisconsin participated. In each pair, one community was assigned to the intervention group and the other to the control condition. The types of community activities undertaken as part of the intervention included: responsible beverage server training, shortened hours for alcohol sales, citizen monitoring of alcohol outlets, use of underage decoys to identify outlets that were selling to underage customers, and educational programs for youth and adults. The project involved hiring a local community organizer in each intervention community to mobilize community members to develop their own specific program to reduce youth access to alcohol.

Results after 2.5 years of the intervention were encouraging. Although not statistically significant, a comparison of the intervention and control communities found that alcohol outlets in the intervention communities checked age identification more frequently and, in general, were more careful in monitoring the age of their customers than were outlets in the control communities. In addition, 18-20 year olds in the intervention communities reported that they were less likely to provide alcohol to younger adolescents and that they also bought and consumed less alcohol themselves (Wagenaar and Perry, 1994).

5. Community Trials Project
The final example is a community-level universal prevention program called the Community Trials Project (CTP). This project sought to reduce alcohol-related injuries and deaths, as well as the resultant trauma, among the entire population of the community (Holder, 1993; Treno and Holder, 1997a). Three pairs of matched communities, one experimental and one comparison community in each pair were enrolled. Each of the three intervention communities used five program components in an attempt to reduce alcohol-related trauma:

Knowledge, Values and Mobilization
. The goal of this component was to help communities become organized around developing and implementing action plans to address local problems. Project staff at each experimental site received consultation from a professional community organizer. Regular on-site technical assistants addressed issues such as keeping the existing community coalition members informed about project goals, media advocacy to gain coverage for the project, and guidance on political and legislative action (Holder, 1993).

Responsible Beverage Service Practices. This component was designed to reduce the probability of persons becoming intoxicated at local bars and restaurants. The focus was on implementing responsible beverage server practices such as eliminating "happy hours," serving standard size rather than oversized or "super-charged" drinks, monitoring alcohol consumption, limiting the rate of consumption among heavy drinkers, promoting food and nonalcoholic beverage consumption, and preventing intoxicated customers from driving. The project staff obtained support for these practices from local hospitality organizations and then provided the training to managers and servers using a standardized curriculum (Saltz, 1997).

Reduction of Underage Drinking. The goal of this component was to reduce underage drinking by decreasing the likelihood of outlets selling alcoholic beverages to minors. The approach was to work with local police to increase enforcement of underage sales laws through practices such as sending warning letters to all outlets informing them of an increased emphasis on enforcement of the laws and the use of underage police decoys to attempt to purchase alcohol. In addition, media advocacy was used to build community support for increased law enforcement efforts (Grube and Voas, 1996).

Risk of Drinking and Driving. The goal to reduce drinking and driving was addressed through expanding news coverage of DUI enforcement, increased use of DUI check-points, and use of improved breathalyzer equipment. A key approach was a media advocacy campaign to publicize the increased risk of apprehension for drunk driving. Project staff and community coalition members worked with local law enforcement to publicize the enhanced DUI enforcement efforts (Voas, 1997).

Access to Alcohol. The main focus of this component was to correlate geographical availability of alcohol with levels of alcohol-related problems. Once problem areas were identified and mapped, project staff and coalition members worked to develop local plans and zoning policies to regulate the density of alcohol outlets. Communities were also encouraged to revoke the licenses of problem alcohol outlets (Grunewald et al, 1996).

The five components complemented and supported one another in a community-level effort (Holder, Treno, Saltz, & Grube, 1997). Lessons learned from the CTP were:

  • Use existing community coalitions. They may require only limited project staff guidance.
  • Local events/festivals and media campaigns can generate community support for prevention projects.
  • Significant community-level impacts at the intervention sites included less likelihood of alcohol sales to apparent minors; fewer alcohol-related traffic accidents; and greater local involvement in license renewal, banning alcohol at some public events, and eliminating problem outlets.

Conclusions

These five examples show how a range of activities addressing the various domains listed in Table 1 can be combined to form coherent programs. They also demonstrate how universal and selective prevention interventions are applied in social work practice. In general, there is a movement from whole populations (universal) to populations that exhibit distinctly higher risk levels (selective) to those with the highest risk (indicated). Along this continuum, the scope of impact becomes narrower and resource and political acceptability costs are affected.

Kreitman (1986) points out that much prevention work has focused on individuals at the greatest risk rather than the general population (selective or indicated approaches). He argues for a shift to universal efforts where the potential impact is much greater due to more people receiving the programs. Even within a particular classification, the target can differ. The community-level universal approach used in the CTP was very different from the youth-focused universal approach in the LST project. Both fit the universal classification because they did not target high-risk communities or individuals. The difference was that the CTP used a community-wide approach while the LST focused only on youth.

Bush (2000) provides a conceptual overview that places prevention strategies within the social work frame. She groups prevention activities in the following ways:

  • providing information
  • promoting awareness and self-efficacy
  • building skills
  • providing healthy alternatives
  • changing norms
  • fostering community collaboration

These six approaches characterize social work practice. Both clinical and community social work skills are represented and both are needed in prevention work. Prevention efforts parallel social work efforts to enhance human well-being, empower people, and promote positive social change. The focus on prevention of conditions that contribute to problems before the problems develop or get serious is at the core of much of social work practice

RECOMMENDED CLASSROOM ACTIVITIES

  1. Brainstorm a number of strategies for the prevention of alcohol use disorders. Your solutions should clearly evolve from the analysis presented in this module! Discuss ways in which to integrate a comprehensive array of approaches into a community-wide system of prevention. What are the barriers to developing this system? What are solutions to overcome the barriers?
  2. Review innovations in prevention of alcohol use disorders that appear in the literature, are being implemented in your area, and/or are presented at conferences (e.g., Society for Prevention Research, NASW, CSWE, Research Society on Alcoholism, etc.). Use the frameworks presented in this module to analyze the innovations and discuss their successes and limitations.
  3. The Encyclopedia of Primary Prevention should be in press during 2003. Assign relevant sections to study groups for review, analysis and reporting. Another significant source of literature concerning the development, implementation, and evaluation of prevention research is the interdisciplinary journal Prevention Science.
  4. Read the article by Begun (1999) that applies a vulnerability/resilience and risk/protection model to the issue of intimate partner violence. As a class, collect information from the literature and from this module that would develop the framework with regard to:

  5. (1) adolescent alcohol abuse and/or
    (2) alcohol use disorders in the general population. Work together to develop your "picture" that should precede planning for intervention.

DISCUSSION TOPICS

  1. What are the social work ethics issues that arise in practicing the various levels/types of preventive intervention (universal, selective, indicated and/or primary, secondary, tertiary)?
  2. How can you, as social work professionals, convince communities, governments, and society to invest in prevention? What are the costs and benefits of doing so? What are the costs and benefits of not investing in it? Be concrete and specific!
  3. Discuss the research issues that arise specific to evaluating prevention programs (i.e., instrumentation/measurement, sampling, study design, inferences from results, timing of results, dissemination and utilization)

References

Barker, R. L. (1999, p. 375). The Social Work Dictionary, 4th edition. Washington, DC: NASW Press.

Begun, A. (1993). Human behavior and the social environment: The vulnerability, risk and resilience model. Journal of Social Work Education, 29, 26-35.

Begun, A. (1999). Intimate partner violence: An HBSE perspective. Journal of Social Work Education, 35, 239-252.

Bloom, M. (1996). Primary prevention practices (p. 2). Thousand Oaks, CA: Sage Publications.

Botvin, G. J., Baker, E., Renick, N. L., Filazzola, A. D., & Botvin, E. M. (1984). A cognitive- behavioral approach to substance abuse prevention. Addictive Behaviors, 9, 137-147.

Botvin, G.J.; Baker, E.; Dusenbury, L.; Tortu, S. & Botvin, E.M. (1990). Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: Results of a three-year study. Journal of Consulting and Clinical Psychology, 58, 437-446.

Botvin, G. J., Schinke, S. P., Epstein, J. A., & Diaz, T. (1994). Effectiveness of culturally focused and generic skills training approaches to alcohol and drug abuse prevention among minority youths. Psychology of Addictive Behaviors, 8, 116-127.

Botvin, G. J., Baker, E., Dusenbury, L., Botvin, E. M., & Diaz, T. (1995). Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. Journal of the American Medical Association, 273, 1106-1112.

Bush, I. (2000). Prevention: A viable and critical component of intervention. In A. A. Abbott (Ed.) Alcohol tobacco, and other drugs: challenging myths, assessing theories, individualizing interventions (pp. 341-379). Washington, DC: NASW Press.

Center for Substance Abuse Prevention. (1995). CSAP communications cooperative agreements: Breaking new ground in health communication. Prevention Pipeline, 8(3).

Commission on Chronic Illness. (1957). Chronic illness in the United States. Vol. 1. Commonwealth Fund. Cambridge, MA: Harvard University Press.

Gordon, R. (1987). An operational classification of disease prevention. In J. A. Steinberg, & M. M. Silverman (Eds.) Preventing mental disorders (pp. 20-26). Rockville, MD: Department of Health and Human Services.

Grube, J. W., & Voas, R. B. (1996). Predicting underage drinking and driving behaviors. Addiction, 91, 1843-1857.

Grunewald, P.J.; Millar, A.B. & Roeper, P. (1996). Access to alcohol: Geography and prevention for local communities. Alcohol Health and Research World, 20, 244-251, 1996.

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Updated: March 2005