The 1ournalof PrimaryPt~ventior~VoL I~ No. 3, 1996

A Community Systems Approach to Substance Abuse Prevention in a Rural Setting 1 Judith R. Vicary, Ph.D., 2,3 Melanie K. Doebler, M. Ed, 2 Jeffrey C. Bridger, Ph.D., 2 Elise A. Gurgevich Ph.D., 2 and Randall C. Deike, M.S. 2

The Community Health Demonstration Project developed a community systems model of program development and interventions which provides consistent, ongoing prevention messages and services across multiple delivery systems and service providers. This model has brought together various sectors of a rural disadvantaged Appalachian community in Pennsylvania to plan, implement, and evaluate a community-wide campaign addressing the prevention of alcoho~ tobacco, and other drug (ATOD) problems. The model for this community prevention effort focused primari~ on the development of community awareness, resources, and programming--capacity building--all of which provides a foundation for continuing attitude and behavior change. Preliminary evaluative data indicate that awareness of local ATOD problems has increased. Moreover, new programming has been implemented and interaction and cooperation among services providers have improved dramatical~ during the course of the project. KEY WORDS: rural; community; capacity building; coalition; substance abuse.

INTRODUCTION Economically disadvantaged rural families represent a significantly underserved population in the United States. People living in rural areas constitute one-fifth o f the Nation's population and one-third o f the country's tCenter for Substance Abuse Prevention Grant Number 1507. ~q'he Pennsylvania State University. 3Address correspondence to Judith R. Vicary, College of Health and Human Developmen4 Pennsylvania State University, 152 S. Henderson, University Park, PA 16802.

9 19% Human~

Pre.~ In~

304

Vicars, Do~l~r, ~ddger, t?,urgev~ and

poor (Duncan & Tickamyer, 1988), yet two-thirds of families living in rural poverty have at least one worker in the household, thus relegating these families to the "working poor." These families are at special risk for a range of health and behavior problems including substance use, especially alcohol, tobacco, and over-the-counter medications (Wagenfeld, 1990). To compficate matters, most rural residents have very limited access to prevention, intervention, and treatment services (Fitchen, 1991). The Community Health Demonstration Project (CHOP), funded by the Center for Substance Abuse Prevention (CSAP) through Penn State University (CSAP Grant #1507), works within one such rural disadvantaged Appalachian community in Pennsylvania. The project's goal is to help develop resources, training, consultation, programming, technical assistance, and coordination with local service providers to address the prevention of alcohol, tobacco, and other drug (ATOD) problems. A range of community data, collected during a previous 5 year longitudinal study of adolescent health and related behaviors including substance use, revealed a significantly high level of alcohol and tobacco use, as well as a need for additional services. The Community Health Demonstration Project has thus developed a community systems model of interventions which provide consistent and on-going prevention messages and services across multiple delivery systems and service providers. This model has brought together for the first time the local school district, the business sector, social services, faith groups, and service providers to plan, implement, and evaluate a community-wide prevention campaign. The remainder of this paper will describe programming and evaluation efforts carded out through this project to date. A brief literature review of the extent of the problem and the programmatic model are followed by a discussion of the Community Health Demonstration Project's philosophy and specific approaches. The target community is described and needs assessment data from the community, school, and local working women are presented. Programming and evaluation efforts are then outlined. Finally, preliminary data from these activities are presented and discussed.

LITERATURE REVIEW Substance Use and Rural Residents

The General Accounting Office reports that alcohol abuse is as serious in rural areas as in urban settings, although these communities have received far less help and attention (Tevis, 1991). Rural youth, for example, represent approximately one-third of American adolescents, located in two-

Rural Community Prevention

305

thirds of American school districts (Helge, 1990). However, they have been seriously neglected in research on and programming for teenage health and well-being (Preston & Mansfield, 1990). Mitgang (1990) noted that "Rural schoolchildren are more likely to face failure because of crime, substance abuse, parental neglect or other factors than city or suburban kids." A study by the National Rural Development Institute found rural youth to be at greater risk on 34 of 39 risk dimensions (Helge, 1990). Other studies (e.g., Sarigiani, Wdson, Petersen, & Vicary, 1990) have indicated lower self-esteem among rural youth relative to suburban youth, a factor often associated with substance abuse. ATOD-related problems are not geographically bound, with a number of surveys pointing out the extent of use in rural settings. Johnston, O'MalIcy, and Bachman (1994), in their national study of high school seniors, report that alcohol use is as prevalent in rural as in urban areas. Other studies note similar results (GAO, 1990; Peters, Oetting, & Edwards, 1992; University of Michigan, 1993). Unfortunately, prevention programs developed and implemented in urban and suburban areas may not easily apply to rural settings. These communities often have problems and limitations unique to their rurality. Prevention Programming Problems in Rural Communities

Although there is no single definition or description of rurality, geographic distances, and/or population density are usually used to distinguish non-urban and non-suburban settings (Wilkinson, 1991). While rural communities are certainly not homogeneous, they tend to share a number of similar problems based on such factors as ethnic composition, physical and social isolation and employment patterns. Compounding these problems, there has been an increase in poverty and mental health problems in these areas (Wagenfeld, 1990), beginning in the 1980's, along with more limited employment opportunities due to globalization of the economy and domestic economic restructuring (Luloff, Bridger, & Graefe, 1994). Most also have a lack of or very limited availability of health care services (Edwards, 1992; Helge, 1990; Human & Wasem, 1991). The GAO (1990) summarizes a number of difficulties for rural communities in developing prevention programs. These include: 1) a lack of acceptance by community members, schools, and agencies; 2) a lack of trained staff; 3) funding limitations, with a higher per-client cost due to diseconomies of scale; and 4) transportation problems, including greater distances for both clients and service providers to travel, as well as a lack of public transportation systems.

Vlcsry, Doebler, lkidger, Gurt,evtch, and Deike

In addition to these socioeconomic conditions, interpersonal factors may limit rural individuals from seeking help with substance abuse and related problems. In areas where "everyone knows everyone else" residents hesitate to seek help because of a perceived lack of privacy;, for the same reason, people are also less likely to report that someone else has a problem and needs help. A mistrust of outsiders or "experts" may also influence use of services. Denegerink and Cross (In Human & Wasem, 1991) note that rural residents often strongly value self-sufficiency and self-reliance. Concomitant with these values, there are strong cultural norms regarding health-care-seeking behavior in rural communities that often cause rural residents to rely on an informal network for health care. They may also postpone seeking care until the problem has increased in severity to a point of interfering with the individual's ability to work or until it is socially acceptable to seek formal health care services (Cordes, 1985; Richardson, 1988; Weinert & Long, 1990). Risk Factors and a Community Systems Approach Recent research has suggested a number of potential risk factors associated with the misuse and abuse of various substances (Gerstein & Green, 1993; Hawkins, Catalano & Miller, 1992; Levitt, Selman, & Richmond, 1991). Hawkins et al.'s review (1992) of 16 potential risk factors categorizes them in two basic areas: 1) those reflecting the social context or environment such as the community and neighborhood; and 2) those within the individuals, and in their relationships with family, school, and peers. In a rural community certain environmental risk factors often significantly influence local use behaviors. These include economic and social deprivation, and community laws and norms favorable to, or even supportive of, alcohol use. A number of individual risk factors in such disadvantaged communities are also present. Family substance use, social isolation, poor family management, early antisocial behaviors, academic failure and low commitment to schooling, early age of first use and substance-using peers are variables often present (Hawkins & Catalano, 1992). Communities directly influence the lives of youth but they also have a strong indirect influence on children and adolescents through their impact on the families and schools in their domain (Brook, Nomura, & Cohen, 1989; Kelly, 1988). Community research also indicates that health and wellbeing can be promoted through the building of social networks that link not only families and schools, but also agencies and organizations throughout the community with the common purpose of collaborating to address

nnnd Communityt~.venflou the needs of children and families (Bernard, 1991; Coleman, 1987; Mill.% 1990; Schorr, 1988). In essence, prevention programming is a process of community development, with a goal of building a locality's capacity to address community problems. This involves a deh'berate attempt to develop communicative bonds between different segments of the local society. The end result of such a process is the development of community among a local population, which, from the perspective employed here, is assumed to be an important factor in individual and social well being (Willrin~gon, 1979).

PROJECT APPROACH The Community Health Demonstration Project's programming is based on a community systems model in which individuals are viewed as members of several different, yet intertwined and interacting, systems. Primary systems include families, peer groups, schools, and worksites. These primary systems are contained in larger systems, such as neighborhoods; communities; and local, State, and national governments. All of these systems are interconnected in some manner, either overlapping, comprising or encompassing other systems. (Hyman & Miller, 1985; Wilkinson, 1991). Using an "upstream" approach of providing resources, training, consultation, program development, coordination and other technical assistance to existing systems (e.g., social service providers, schools, and businesses), allows for change at the systemic as well as at the individual level. This approach is consistent with recent Federal efforts implementing empowerment-zone legislation, which potentially results in a devolution of resources while developing local systems of services and supports. While the Community Health Demonstration Project focuses on preventing substance abuse within the community's pregnant and postpartum population, it seeks to address this audience through all the systems that affect individual and family well-being in the community. Because of the socially normative status of alcohol and tobacco use in rural areas, women are at particular risk for misusing these, and over-the-counter and prescription medications during pregnancy and postpartum, make an "upstream" approach especially viable. With a systems approach, the CHDP works with all social service providers who have direct contact with pregnant and postpartum women, providing substance abuse-related prevention messages and services targeting all women of childbearing age in the community, and the personal and social systems in which they interact. For prevention to be most successful, it was recognized that CI-IDP programs must be comprehensive, targeting all of the systems and subsys-

308

ViemT, Doebler, Bridget, Gurgevich, and Deike

terns that potentially affect substance abuse at the individual level: the farofly, peer group, school, workplace, and general commtnlity. A range of methods was also needed, including awareness and education, personal skill.~ development, positive alternative activities and improved community norms and standards regarding ATOD use. It was also important that members of the community would determine, with the help of the project, what the local problems and needs were, and how these could be best addressed. Community ownership and management of the prevention initiatives are essential for future integration into existing local agencies and settings (W'dkinson, 1994). Furthermore, since capacity building was an explicit goal of the project, extensive local involvement was imperative if prevention efforts were to continue after the project was completed.

Community The target community was one rural, geographically contained school district in Appalachian Pennsylvania. The district serves a two-county area of approximately 25 miles in diameter, made up of a number of small towns, boroughs, and isolated areas, seven municipalities in all. The residents are white, low to low-middle income, and mostly of European descent. A majority of families emigrated to this area up to three generations ago, primarily to work in the local mining and lumbering industries initially, and subsequently, for employment in the garment and cigar factories. The already poor local economy has experienced a severe downturn in the past decade, with the closing of most of the region's mines and manufacturing plants. Over 45 major businesses have closed since the 1980 census, and there is major unemployment and high underemployment in the area, with almost all families affected to some degree. Distance from any other major labor market has also increased the scope, severity, and duration of employment problems. A recent community survey of women aged 18-35 found that 20% reported household incomes below $15,000, and 6%, under $7,500. School district census data show that grade school was the highest level of education achieved by 25% of the area adults, while 44% completed high school. More than 20% of eighth graders recently scored below the national cutoff for remedial classes in reading and 25% were below the cutoff in math. These figures reflect the district's economic and educational deprivation. Alcoholism is also recognized as a serious problem in this community, as it is in to many other disadvantaged areas, along with a relatively high incidence of alcohol-related violence and crime (Rudella, 1990). Commu-

Rnral Community Preveutieu

309

nity isolation, local norms, high unemployment, limited opportunities and a lack of recreational programs exacerbate drinking behaviors. Smoking levels are also high for both youth and adults, and illicit substances are used with increasing frequency. In fact, recent police investigations determined that a major Eastern drug distribution center was being operated out of this community (Robertson-V~/'dliam.% 1994).

Needs Assessment Community Survey A major effort during the first year of the project included a needs assessment, based on community design, input, and oversight. Project staff met with community leaders, agency representatives, and local women to form a community "Ihsk Force and to develop a survey questionnaire. Local input was critical in determining the substance use and health issues to be assessed. Three content areas emerged from the "l~sk Force's suggestions: (1) self-reported experiences with substance use; (2) pregnancy experiences; and (3) general attitudes and opinions about health and well-being in the community. Concurrent with survey development, meetings were held with community representatives and needs assessment experts to determine the most appropriate and efficient way to gather the data. After considerable methodological review, and within resource constraints, a decision was made to collect data through a mailed survey of randomly sampled women aged 18 to 35, the prime childbearing ages; those under 18 were not surveyed because they were minors, although this community has a significant rate of teen pregnancy. With approximately a 70% return rate, the respondents identified three major problem areas within the community: nutrition, mental health disorders including substance abuse, and physical health problems. The most common family problems reported included emotional problems, alcohol use and violence. As in so many other communities, the interrelationship of substance use and other family problems is evident and suggested the need for, and access to, prevention and intervention services.

Needs Assessment Student Survey In addition to the community survey, students at the district junior high school were surveyed on a range of developmental, behavior, and needs areas, in order to determine their developing substance use attitudes and behaviors. Using a longitudinal cohort sequential design, a self-report survey, used to assess a variety of factors related to adolescent development, was

Vkary, Ileebler, addt,er, ~

310

and

adminL~tered to students in the 7th, 8th, and 9th grades. These same students were surceyed Annually during the first 4 years of the project. It b important to note that the data were initially used as a needs assessment to help district adminLqrators and teachers I ' ~ i T ~ the extent and type of ATOD use by their students. Based on these findino~,x, it was possible to begin to initiate teacher in-service awareness p r o g r a m m i n g ; followed in the 4th year by the prevention infusion model for teacher skill development. The results of the student surveys indicated the critical need for additional, and earlier, prevention efforts. For example, in the fall of 1991, just after the CHDP began, local 8th and 9th grade students had much higher levels of use compared to national data from the Johnston, O'Malley and Bachman (1994) survey at that time (see "lhble 1). The between-subjects results indicated a si~ificant difference between the boys and girls, with the males reporting a higher frequency of drunkenness. Older students also reported siLmificantly more drunkenness; both findings are consistent with national data. Later surveys show each 7th grade cohort "catching up" with higher levels of use by 8th or 9th grade. These findings have been important to the district in recogpizing the extent of their problem and the need for a comprehensive K-12 prevention plan. They are also becoming aware that all teachers and parents, as well as the community at large, have a role to play in youth development and substance abuse prevention.

Needs Assessment: Women Employees Survey Finally, as part of the on-going planning process, a needs assessment checklist designed to assess current issues of health concern was distributed Table 1. Thirty-Day Use Data Comparisons, 1991 Percent

Distribution of Responses Target Community

National Sample

8th Grade Been drunk Smoked cigarettes Used marijuana Used inhalants

19.3 24.9 3.6 8.9

7.6 14.3 3.2 4.4

10th Grade Been drunk Smoked cigarettes Used marijuana Used inhalants

34.2 31.8 8.9 6.3

20.5 20.8 8.7 2.7

311

RurslCommu~PreveatJoa

to female employees in a number of community factories. Women were asked to cheek program topics of interest or concern to them. This needs assessment resulted in a list of priorities for programming which included managing stress, raising drug-free kids, and helping a friend with a drug or alcohol problem. The results of each of these needs assessment efforts was presented to and discussed by the Community "l~sk Force and was the basis for program development efforts by the participating agencies and organiTations with the CHDP Project. All programming decisions have been made in conjunction with local groups and individuals, with regular and on-going planning, assessment, and program modification.

PROGRAM A C r l v r r t ~

Interagency Coalition Building A critical early effort was the formation of an Interagency Coalition (IAC) to link agencies responsible for serving the health needs of women and their families in the target community. The community is divided by a county line which results in a bisection of service responsibilities between two counties. Inequities exist between the counties' services. Distance and agency service boundaries limit communication between the counties' service personnel. The Interagency Coalition was developed to help ATOD prevention and treatment agencies to overcome service delivery problems on both sides of the county line. The five original Coalition members soon expanded their efforts to include a wide range of other service providers. Currently, 56 agency representatives attend Interagency Coalition meetings. This referral, support, and information-sharing group has met monthly since January 1992, giving participants an opportunity to discuss community health issues and allowing agencies from both counties to work together to provide more comprehensive care to the entire community. Agencies are also now working cooperatively, many for the first time, to develop and provide services to individuals and families who may require prevention and remediation of alcohol, tobacco, and other drug use, and related problems. Through the efforts of the IAC, a number of cooperative, jointly-sponsored programs and materials are newly available throughout the community. Examples include: a local human service directory, adolescent sexuality programs, a family issues series, adolescent development programs, and a parenting resource guide.

312

Vicary, Doebler, Bridget, Cmrgevkh, ~

Delke

Prevention Programming

The CHDP's next major effort was a Year of Prevention! campaign. This cooperative effort is a public awareness and educational campaign promoting prevention of ATOD abuse throughout the whole community. It was launched when, recognizing their shared goals and objectives, the school district's Drug and Alcohol Prevention Advisory Committee merged with the CHDP "Ihsk Force. The prevention campaign evolved into one of the project's most comprehensive efforts, using a wide variety of approaches and methods involving local media, businesses, social services, youth groups, schools, faith community, and service organiTations. Examples of Year of Prevention! programming include newspaper articles and inserts, public presentations at service organization meetings, and sporting events, proclamations of support for prevention, billboard advertisements, church programs, business involvement and radio shows. A logo was developed for the campaign which was then used on all program materials, ads, billboards, and in a "sticker blitz" resulting in the distribution of over 3,000 logo stickers in one weekend. Easily recognizable, this logo has appeared throughout the area, from grocery bags and restaurant place mats, to music programs and business handouts, creating community-wide awareness of the Year of Prevention! The Year of Prevention! has also been the stimulus for cooperative programming within existing community groups. For example, the Interfaith Prevention Council developed a discussion series; a youth activity guide was produced detailing all local opportunities for youth participation; and area-wide Health EXPO and Business EXPOs were held, all including substance abuse prevention programming. Based on the first year's success, the project evolved into the Year of Prevention II, adding new activities, resources, and programs to the campaign. The school district has played a major role in the CHDP initiatives, from supporting teacher in-services devoted to prevention to student development day opportunities. Initially, junior high school teachers and counselors received an introduction to prevention programming, which was then followed by a three-credit course on curriculum infusion entitled "Prevention in Your Classroom." Teachers at the secondary level were helped to develop lesson plans integrating prevention messages and methods into their own subject areas and grades. Participants were observed and given feedback by CHDP staff when they implemented the integrative lessons. Another innovative program was developed for all students in grades 9 through 12. Annual Student Development Days were conducted as student "inservice" programs, with a variety of workshops, presentations, and activities promoting positive development and problem prevention. Stu-

Rural Communi~ Preventiou

313

dents chose topics important to them, including enhancing serf-esteem, building healthy fl"iendships, helping a friend with a substance abuse problem, communication skills, coping skills, dating violence, eating disorders, and depression and suicide. Area professionals from 25 agencies volunteered their time to facilitate the small group workshops, and many other community volunteers helped with the organization and logistics. Prenatal and Postnatal Programming The needs assessment process revealed an absence of prenatal and parenting services as a significant problem for the area's families. Thus, a final area of CHDP program initiation was the development of such educational opportunities in the community. In conjunction with the local Family Health Services, prenatal classes were developed and are now offered regularly throughout the year. Recognizing the on-going needs of pregnant and postpartum women, other groups from the Interagency Coalition helped develop birthing classes and postnatal home visit programs as well. One of these is offered through the Cooperative Extension Service, using a curriculum entitled Visits with You and Your Baby. Project staff wrote substance abuse-related prevention sections for use with each home visit, and these have now been published by the Extension Service, thus increasing their availability to a variety of agencies, both in this community, and throughout the country. Recently, an IN-TOUCH program was begun as a single source information and referral network for women to access education, prevention, intervention, and treatment options in this rural community. In addition to increasing access opportunities, the network also provides health service agencies with a client recruitment center. Local agencies can publicize their services and programs through the IN-TOUCH system, and women can register there to be notified of various programming. In summary, the CHDP has acted as a community-based catalyst for recognition of the problem of alcohol, tobacco, and other drug abuse. It has brought together area resources--individuals and agencies--to plan and implement new prevention and intervention approaches at all levels of and locations in the community. From health professionals to local volunteers, grocery stores to area businesses, school activities to newspaper series, church programs to youth groups--the messages are clear, consistent and community-based, with a place for every segment of the population to join. This systems approach could not have occurred without the full cooperation and support of the community and its residents. The ideas begin

314

Vicary, Doebler, Bridget, Gurgevich, and Detk~

there with the CHDP helping to bring these about by providing technical assistance, resources, contacts, and encouragement.

RESULTS As the project developed, a number of evaluative activities were undertaken at different levels. These have been used to provide feedback for planning and program revision throughout. Surveys have been conducted of the Interagency Coalition members, of community women of childbearing age and of a cohort of students initially in junior high school when the project began. Although the CHDP is still in process, some preliminary results have suggested directions for continuing or expanded programming efforts.

Interagency Coalition Evaluation Two years after the Interagency Coalition (IAC) was formed, members were interviewed by phone regarding their communication and collaboration with other members, their awareness of available resources, and their impressions of the project's impact on the community. It was evident that many participants had also joined The Year of Prevention! Task Force as a result of the Coalition, and contributed their time to both efforts. Members reported that, as an organizational entity, the IAC had provided benefits in three ways: 1) by increasing interaction among individuals and service agencies, as well as among the agencies themselves; 2) by increasing their awareness of and access to resources available to the community; and 3) by the introduction of The Year of Prevention.t, which increased the community's awareness of drug and alcohol issues, serving to draw the community together for the common cause of prevention. Eighty-three percent of those interviewed reported increased interaction with other members/agencies, including by phone, through referrals and joint meetings and by written communication. Eighty-seven percent noted new collaborations as a result of their involvement both on specific projects and on general concerns, as well as policy development. More than a third also reported conducting staff training or participating in community level meetings as a result of their participation in the Coalition. In addition, members noted that they had received resources and materials from the CHDP, which they found to be very useful. In short, these results suggest that the Interagency Coalition is providing the kinds of communication linkages that promote cooperation and collective action on an on-going

1~

Commnnlty P r ~ f l u

315

basis. This capacity building was, and continues to be, a goal not only for the CHDP, but for the IAC and community. Community Evaluation At the community level, the primary evaluative instrument consisted of a survey marled to a stratified random sample of community women ages 18 through 35. This was first used in 1991, before programming began, and again in 1994. In both cases, the population was identified through per capita tax lists of all individuals aged 18 and over. Based on data from the 1990 census, a 10% random sample was then drawn. A modification of DiUman's (1978) Total Design Method (TDM) was used to obtain as high a response rate as poss~le. Advertisements were placed in the local newspaper and on the radio explaining the survey's purpose and who would be contacted. A cover letter was included with the mailed survey to provide more details about its purpose and value, how the respondent was chosen and the guarantee of confidentiality. Two weeks later, another round of surveys was mailed to those who had not yet responded, followed by a reminder postcard several weeks later. These procedures yielded a return rate of 73% in 1991 and 70% in 1994. When the first survey was conducted, the respondents were, on average, 28 years old, with 70% married, and 40% working full time outside the home. By 1994, there was a substantial decrease in the number married (58%), and an increase in those working outside the home (48%). The number who have lived in the community for 10 years or more has remained constant at 76%. As noted earlier, this community is like many similar rural areas in America, experiencing a severe economic downturn over the last decade. These dismal conditions are reflected in household income figures: in 1994, 16% of respondents reported household incomes below $15,000 and 7%, below $7,500. Considering the stress that this kind of economic deprivation can place on families, it is not surprising that a si~,nificant proportion of participants reported (23%) being depressed 10 or more days per month. At both survey periods, women who reported being depressed that often were more likely to use over-the-counter medications on a daily basis than were their non-depressed counterparts. Reported use of alcohol has declined slightly during these 3 years, from 35% to 32% drinking monthly or more often and from 12% to 8%, weekly or more often. The most encouraging finding concerns use by pregnant women, with 15% initially reporting drinking monthly or more often during pregnancy; that figure dropped to 7% in 1994. Another positive direction

31~

Vkary, Veeb~, erk~r, ~

nd

is seen among women who were pregnant during the project yeats; they were sitmificantly less likely to use over-the-counter drugs weekly or more often than were women who were pregnant before the project began. Unfortunately, the percentage of women who reported smoking more than 1/2 a pack of cigarettes a day has increased from 19% to 23%. However, smoking a pack or more a day while pregnant decreased from 16% to 8%. Interestingly, 60% of the smokers started to smoke before the age of 15, and 78% have tried to quit smoking. For those who report having quit, 28% quit within the past 6 months, and 50% within the past year. The survey participants have become more aware of communityproblems during this time, with an increase in concern over alcohol abuse, smoking, and illegal drugs. A similar pattern holds for their perception of problems facing adolescents, that is, again alcohol, tobacco, and illegal drugs. When asked about their awareness of community programming, almost half were aware of the Yearof Prevention!, with the school, radio, and newspaper responsible for most information. Ninety percent of the respondents knew of at least one of the community prevention programs, and 70% were aware of at least three. Thirty-five percent had participated in one or more of the school-based efforts.

SUMMARY In conclusion, initial process and outcome data indicate both a perceived and real value from the development of the Community Health Demonstration Project. Increased interaction, referrals, and programming have resulted from the organization of the Interagency Coalition, ultimately improving access to and service delivery for clients. School data have provided concrete evidence of the extent of ATOD use by young adolescents, emphasizing the need for earlier and more comprehensive prevention efforts. The community-wide approach has also brought attention to a need for parental and youth-serving agencies' increased, on-going involvement in promoting positive, healthy development from prenatal stages through adolescence, and the importance of adult role modeling of healthy behavior choices as well. It is not possible, of course, at this point to expect significant decreases in alcohol, tobacco, and other drug use, especially in opposition to national data which indicate increases in many uses levels with certain age groups (e.g., Johnston, et al, 1994). After only 2-1/2 years of programming, much of which focused on organizing, planning, and coordinating for implementation, measurable individual behavior change would be hard to determine.

317

Despite these caveats, preliminary evaluative data indicate that awareness of local ATOD problems has increased. Moreover, new programming has been implemented and interaction and cooperation among service providers has improved dramatically during the course of the project. The model for this community prevention effort focused primarily on the development of community awareness, resources, and programming-capacity building--all of which provide a foundation for on-going attitude and behavior change. Further programming, continued over time, on multifaceted levels, in multiple settings, will provide an opportunity for future evaluations to determine the behavioral effects of this community systems approach to prevention.

~

N

~

Bernard, B. (1991). Fostering resi~ncy in kid&" Protective factors in the family, school, and community. (Report No. EA 023 260). Portland, OR: Western Center for Drug-Free Schools and Communities. Brook, J. Nomura, C., & Cohen, P. (1989). A network of influences on adolescent drug involvement: Neighborhood, school, peer, and family. Genetic, Social, and General P ~ o t o ~ Monoyap~ 115(1), 303-321. Coleman, J. (1987). Families and schools. Educat/onal Researcher, 16(6), 32-38. Cordes, S. M. (1985). Biopsychosocial imperatives from the rural perspective. Socia/Sc/enee Medicine, 21(12), 1373-1379. Dillman, D. (1978). Mail and telephone surveys: The total design method. New York: Wiley. Duncan, C., & Tickamyer, A. (1988). Poverty research and policy for rural America, American Sociologis~ 19(3), 243.258. , Edwards, R. (1992). Drug and alcohol use by youth in rural America: An introduction. In R. W. Edwards (Ed.), Drug U~e in Rural American Communities (pp. 1-8). Binghamton, NY: The Haworth Press, Inc. Fitchen, J. M. (1991). Endangered spaces, enduring places: Change, identi:y and swvival in rural Americ,, Boulder, Colorado: Westview Press. Gerstein, D., & Green, L (1993). Preventing drug abuse What do we know? Washington, DC: National Academy Press. Hawkins, D., & Catalano, R. (1992). Communities that care: Action for drug abuse prevention. San Franciso, CA: Jossey-Bass. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early childhood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64-105. Helge, D. (1990). A national study regarding as-risk students, Bellingham, WA: Western Washington University, National Rural Development Institute. Human, J., & Wasem C. (1991). Rural mental health in America. Amer/can Psycho/og/st, 46, 232-239. Hyman, D., & Miller, J. A. (1985). Community systems and human services. Dubuque, Iowa: Kendall/Hunt Publishing Company. Johnston, L D., O'Malley, P. M., & Bachman, J. G. (1994). National survey resu~ on drug use from monitoring the future study. Vos I NIDA 1975-1992). (DHHS Publication No. ADM 93-1397). Washington, DC: U.S. Government Printing Office. Kelly, J. (1988). A guide to conducting prevention research in the community:. First steps. Prevention in Human Services, 6(1).

318

Vk~-y, Doebler, Brtdger, Gurgevich, and Deike

Levitt, M., Sclman, R., & Richmond, J. (1991). The psychosocial foundations of early adolescents' high risk behavior:. Implications for research and practice. ]ourna/ofResem~ on

~

I(4)

340-378.

Luloff, A. E., Bridger, J. C., & Graefe, A. R. (1994). Assessing rural tourism efforts in the United States.The Annals of Toutwn Research, 21, 46-64. Mills,11. (1990). Substance abu.~ dmpota and delinquencyprevention:The Modeflo-H _o~e~_____,~_ Gardens eady interven0onproject Report presented at the Wmth Annual Conference of Psychology of Mind. Mitgang, L (1990). Report: Rural kids more susceptibleto drugs, crime. Jouvna/Amev/can, p. Bg.

Peters, V. J., Oetfing, E. P,.,& Edwards, R. W. (1992). Drug use in rural communities: An epidemiolo~. In R. W. Edwards (Ed.), Drug Use in Rura/Amev/can Commun/t/es (pp. 9-29). Bin~hRmton, NY: The Haworth Press, Inc. Preston, D. B., & Mansfield, P. K. (1990). Assessing the health states of rural people: An analysis of American studies 1980-1985. In W. Ward & F. Lewis (F.ds.)Advancea in Health Educat/on and ~ 3. Richardson, H. (1988). The plight of rural women. Women and Health, 12(3), 41-54. Robertson-Williams, R. (1994, April 28). Drug-bust breaks up ring:. Kingpin from Philipsburg. The Pmor.~ pp. 1, 6. Rudella, M. A. (1990). Factors affecting the tOil~_ntlon of human service resomves in a rural eastern commune. Unpublished Master's Thesis, The Pennsylvania State University, University Park, PA. Sarigiani, P.A., Wilson, J. L, Petersen, A.C., & Vicary, J. R. (1990). Self-image and educational plans of adolescents from two contrasting communities. Journal of Early Adolescowe, I0, 37-55. Schorr, L. (1988). W'uhinour reach."Breaking the cycle ofdbadvantage. New York: Doubleday. Tevis, C. (1991). Rural health. Successful Fainting, 89(1), 64. U.S. General Accounting Office. (1990). Rural drug abuse prevalenc~ relation to crime and programs. Washington, DC: Author. University of Michigan (1993). News and Information Services. (Available from Diane Swanbrow, 412 Maynard, Ann Arbor, Michigan 48109-1399). Wagenfeld, M. A. (1990). Mental health and rural America: A decade review. Journal of Rural Health, 6~ 1-27. Weinert, C., & Long, K. A. (1990). Rural families and health care: Refining the knowledge base. Mart/age and Fam//y Rev/nv, 15(0 , 57-75. Wilkinson, K. P. (1979). Social well-being and community. Journal of the Community Development Society, 10(1), 5-16. Wilkinson, IC P. (1991). The cornmun~ in tara/Ameba: Westport, Connecticut: Greenwood Press. Wilkinson, K. P. (1994). Rum/community development and societal well-being. Paper presented at the annual meetings of the Rural Sociological Society, Portland Oregon.