The Yournal of Prima~y Prevention, Vol. 16, No. 1, 1995

Enhancing Adoption of an Alcohol Abuse Prevention Program: An Application of Diffusion Theory Molly Laflin, Ph.D, 1 Elizabeth W. Edmundson, Ph.D, 2,4 and Sarah Moore-Hirschl, Ph.D. 3

The purpose of this study was to apply diffusion theory (Rogers, 1983) to an alcohol abuse prevention program in order to enhance program adoption. Three of the four stages of diffusion theory (dissemination, adoption, and implementation) are discussed relative to the development and implementation of a program designed to increase awareness of the destructive effects upon children who live with an addicted parent of living with that parent. The program also focused upon resiliency building strategies to use with children in order to mitigate the harmful effects of addiction in the home. Empirical data are presented concerning the dissemination, adoption and implementation phases of the program. KEY WORDS: diffusion;CoAs; evaluation.

As a program moves from the research and development stage to a real-world setting, the extent to which it is a success or failure largely depends upon who adopts the program and to what degree it is implemented. The application of diffusion theory (Rogers, 1983) in the planning and evaluation of substance abuse prevention programs is a useful, theoretical approach to ascertaining the process and extent of program adoption. Diffusion (Rogers, 1983) refers to how an idea or program begins with a few, 1Bowling Green State University,BowlingGreen, OH. 2University of Texas, Austin, TX. JUniversity of Puget Sound, Tacoma, WA. 4Address correspondence to Elizabeth Edmund.con,Ph.D., Bellmont Hall, 222, Universityof Texas, Austin, TX 78712. 75 9 1995 Human S~ences Pre~, Inc.

76

Lafiin, Edmundson, and Moore-Hirschl

innovative people, expands to a group large enough to form a critical mass, and then spreads throughout a community or geographic region. The four stages of the diffusion process are dissemination, adoption, implementation and maintenance. Evaluation of the diffusion process includes identification of the potential barriers to successful implementation and the mechanisms that facilitate individual and institutional acceptance of a program. This paper describes an application of diffusion theory in the development of a Children of Alcoholics (CoAs) training program for educators and other professionals working in educational settings with 5th through 8th graders. The relative effectiveness of the training was examined within the framework of the four stages of diffusion theory (Rogers, 1983).

RATION,ALE FOR COA FOCUSED PREVENTION PROGRAMS The limited availability of and accessibility to facilities for adolescent substance abuse, compounded by relatively poor recovery rates, magnify the importance of primary prevention in combating the problems of alcohol and other drug abuse among this population. Presently the estimates of the number of children of alcoholics under the age of 18 range from 6.5 million (Woodside, 1988) to 28 million (West and Pfinz, 1987). Increased risks for substance abuse and other symptomatology of maladjustment, as well as the potential for resiliency, among young CoAts have been described extensively in the literature (Roosa, & Beals et al., 1990; Roosa, & Gensheimer et al., 1990; Sher et al., 1991; Tharinger & Koranek, 1988; Werner, 1986). The almost universal acceptance of prevention through education has yielded a plethora of alcohol and drug education programs in the last decade. However, conclusive evidence on the most effective prevention approaches with CoAs remains elusive (Burk & Sher, 1988; 1990; Roosa, Beals et al., 1990; Roosa, Gensheimer et al., 1990; Sher et al., 1991; Tharinger & Koranek, 1988). A scientifically legitimate criticism levied against many prevention programs is the lack of formative or summative evaluations that address the efficacy and relative effectiveness of these efforts. Indeed, until recently, little evidence of the effectiveness of substance abuse prevention programs targeting the general student population appeared in the scientific literature (Bangert-Drowns, 1988; Brandon, 1992; Hanson, 1992). Moreover, the minority of programs that have reported a strong evaluation component tend to focus upon the immediate or short-term impact upon the student in the program, rather than on the extent of program adoption within a particular educational system. Yet in order to create and sustain individual behavior change, social and institutional infrastructures

Enhandng Adoptionof an Alcohol~

PreventionProgram

77

must be in place locally and regionally to provide leadership and continued support (Best, 1989; Ewart, 1991; Wallerstein, 1992). Evaluation methods that examine the linkages between the process of program implementation and behavioral outcomes for the organization as well as for the target audience provide the most useful evidence of the success or failure of a program (Brandon, 1992). However, evaluation of the program adoption process has received scant attention in the field of alcohol and drug education. Diffusion theory is particularly well suited for this type of evaluation because how a program moves through the stages of dissemination, adoption, implementation and maintenance can be documented, and the strengths and weaknesses of the program at each stage can be identified. This paper describes an evaluation strategy that goes beyond commonly used short term student outcome measures to address the larger issue of diffusion of successful programs. Children of Alcoholics: Building Resilience to Enhance Success (CoA:BRE~), was a program designed to reduce the risk for substance abuse among CoAs by training frontline educators in strategies to enhance students' resilience. The results of the pilot phase of the program, with particular focus on the salient features of the program dissemination, adoption, and implementation processes (i.e., first, second, and third stages of diffusion) will be described. Next, empirical data related to several features of successful diffusion efforts are described. Finally, revisions to the evaluation plan for the second wave of trainings are discussed.

METHOD Dissemination

Rationale for Selecting the Target Audience The first stage in the diffusion process is dissemination. This phase involves marketing and recruiting educators so that the appropriate audience is informed and persuaded to attend. The basic idea is to attract "early adopters," those individuals with professional or personal interest in this issue who can provide local leadership and support for the program. Children of Alcoholics: Building Resilience to Enhance Success is a training program funded through an innovative alcohol abuse education grant from the United States Department of Education (USDE). The purpose of the project, directed at a twelve state region in the northeast, is to train educators who work with children in grades 5-8 in strategies designed to

Edmundlso~and Moore-Hlrsehl

78

mitigate problems associated with alcoholism in the family. The goal of the project is tO provide frontline personnel across the community and professional infrastructure with useful information about specific problems faced by young CoAs. The training promotes an understanding of the unique characteristics of CoAs and strategies frontline personnel can use to build their resiliency skills as a means to reduce the risk for alcohol and other drug abuse. Education professionals working with students in grades 5-8 were the target audience specified in the grant proposal for several reasons. With the exception of parents/guardians, educators are the primary adults who interact with students in this age group on a frequent, ff not daily basis, and therefore are more likely to notice symptomatology of maladjustment. A recent survey of elementary and middle school teachers indicated that more than half of the teachers felt inadequately informed about the problems and needs of young CoAs, and about the same percentage felt that an in-service training on the effects of parental alcoholism was warranted (Knight et al., 1992). The majority of the survey respondents were interested and willing to educate and assist CoAs (Knight, et al., 1992). Additional research on health communication campaigns for substance abuse prevention among high risk youth including CoAs has indicated that these efforts should begin at grades 5 and 6, because many students initiate substance use/abuse in junior high school (Backer et al., 1992). Research also supports increasing awareness of the broader social and developmental contexts in which adolescent substance abuse occurs, and addressing the influences of parents, role models (peers and adult), and the media (Backer et al., 1992). Therefore, the following approaches were implemented to reach as many of those frontline personnel as possible in the geographic areas specified in the grant proposal.

Recruitment Strategies The program was voluntary; therefore, in order to ensure participation, social marketing techniques were employed (Bloom & NoveUi, 1981). A marketing strategy to attract and train large numbers of ~ontline educational personnel, rather than reliance upon a traditional trainer-of-trainers model, was selected for several reasons. One supposed advantage of the traditional trainer-of-trainers model is that a small number of hand-picked individuals (preferably community gatekeepers) would be more likely to attend an in-depth two to five day training (the norm for this model), and subsequently train additional educators in that geographical area (usually via one day, in-service programs). The conventional thinking is that: a)

Enhancing Adoption of an Alcohol Abuse Prevention Program

79

these trainers serve effectively as "early adopters" in their communities or geographic regions; and b) large numbers of f~ontline personnel would be unable to leave their work settings for so long a period (two to five days). Given these assumptions, the trainer-of-trainer model would be more pragmatic and efficient. However, there are several caveats to the traditional trainer-of-trainers model. These trainers typically are not content experts: their skills are usually strongest in curriculum delivery approaches. A substantial proportion of these two-to-five day trainings commonly promote and utilize experiential activities to enhance presentation of the content, not in-depth understanding of the content itself. The working assumption of this model is that skillful trainers can deliver most types of content once they have acquired general presentation skills. However, we found no empirical evidence to support the efficacy or effectiveness of this model in substance abuse prevention. Indeed, the notion that generallst trainers can become proficient in this particular content area in such a short amount of time has never been documented in the scientific literature. Moreover, there is no evidence available to support the idea that the individuals selected to be trainer-oftrainers are indeed influential or effective "community gatekeepers" or "early adopters" for substance abuse prevention efforts. These limitations prompted a different approach to reaching the desired target audience. An internationally known expert and co-founder of the National Association of Children of Alcoholics who has devoted over twenty years of study in the area of CoAs was selected as the trainer for the programs. His reputation as an effective, knowledgeable and credible speaker attracts large numbers of people to professional seminars as well as general public presentations throughout the country. To address the concern of audience-appropriate and effective delivery strategies, the seminar was designed to present the latest research findings in a practical and useful way, which should help motivate the participants, in turn, to use the information in their daily interactions with students and colleagues. Rather than attempting to pre-determine the early adopters and influential gatekeepers in each community across twelve states, a "fish net" approach to recruitment was employed. To ensure that the net would be wide enough to include those whose motivation and skills would prompt them to be local leaders in terms of implementing and further disseminating the seminar information, the alcohol and drug abuse coordinators in the departments of education in each of the twelve states were contacted for assistance in recruiting. Some states provided personal mailing labels for every educator, grades 5-8, including teachers, principals, drug and alcohol abuse coordinators, guidance counselors, librarians, and nurses. In states where only lists or labels for the principals or schools were available,

80

latflln, F.dmundson, and Moore-Hirxhi

three to five brochures were sent to each school. A few state coordinators were willing to personally contact all of the alcohol and drug abuse prevention coordinators in their states to promote the program. Press releases were sent to the major newspapers in each region, and mailing lists were acquired for DARE officers and alcohol and drug abuse prevention specialists through the state certification boards. A small pilot study revealed that educators receive approximately 3-4 brochures each week offering professional development training opportunities. In order to compete successfully, Children of Alcoholics: Building Resilience to Enhance Success had to be perceived as unique and useful to the target audience. With the help of several area teachers, a selection of brochures offering training program~ were obtained. These examples from other trzining program~ were shared with the design firm that developed the marketing brochure. The intent was to develop a brochure that would stand out by being creative and inviting, but which was not "too slick." The brochure addressed the issue of credibility by describing the credentials of the speaker (who also has high name recognition in this field) and by emphasizing that the program was sponsored by a grant from the USDE. Potential participants were also offered free instruction manuals and audiovisual materials (i.e., a resiliency building manual and a multimedia packet of materials including activity books, audio and video cassettes, and special texts dealing with the unique problems of children from different cultural and ethnic backgrounds) developed from another USDE grant as an inducement to attend. Approximately 100,000 brochures were sent to educators in twelve states inviting them to participate in the one day trainings. The six training sites (Princeton, NJ; Baltimore, MD; Columbus, OH; Pittsburgh, PA; Syracuse, NY; Portland, ME) were selected to be geographically accessible to the largest number of people in the twelve state region. These sites were also chosen on the basis of adequacy of facilities, quality and price of meals, availability of parking, and willingness of the staff to meet special training needs (e.g., audio visual equipment). A one day training format was chosen because it would allow the greatest number of frontline personnel to attend the seminar. The grant subsidized the cost of the training, which resulted in a low cost registration fee that was affordable for the target audience. Meals and refreshment breaks were provided on-site as an inducement to attend the training and to foster group cohesiveness and sharing of information. A further inducement to attend the training was the availability of certificates of attendance and continuing education credits. Thus, to enhance the dissemination of the training, large numbers of frontline educators were recruited using a competitive brochure. In addi-

I~,nhanc~ Adoptim Of im Alcohol Abuse Pl'eVelltton Program

81

tion, the seminar was made appealing to the participants by offering a credible and well-known speaker, continuing education units, a low cost registration fee, meals, useful handouts, a resiliency manual and a culturally sensitive multi-media kit. Adoption

In the field of health promotion, adoption refers to the process of persuading participants to embrace a tangible program or product, a specific content, or a philosophical paradigm/belief system. The CoA:BRE~ training focused on common experiences associated with the effects of alcoholism on the family, with particular emphasis on specific content and strategies to apply with children. The primary topics addressed in each seminar included the following: a) a description of the alcoholic family experience; b) characteristics of CoAs; e) professional issues related to working with CoAs; and d) building resiliency skills in students. Handouts of the major points emphasized during the conference were distributed to each participant. Seminar Features Designed to Influence Adoption

Several interrelated and interdependent features of successfully adopted programs have been identified through research on applications of diffusion theory. Orlandi et al. (1990), provide a detailed discussion of those features:

compatibility, flexibility, reversibility, relative advantage, complexity, cost-efficiency, and r/s/c. The first feature indicates that the greater the compatibility between the economic, socio-cultural and philosophical value systems of the adopters (in this case the education professionals participating in the CoA training), the greater the extent of implementation at the local level. The second feature, flexibility, refers to the capacity to isolate the strategies presented at the training and utilize the separate components in a manner that best meets the needs of the adopter (Orlandi et al., 1990). Educators and other professionals who comprise a community's educational infrastructure may find that some of the training strategies are more appropriate and easier to implement in their work setting than others. The ability to pick and choose components that best suit one's needs increases the probability of adoption. Reversibility means that if the program does not work out and the adopter wishes to revert to a previous approach, reversal can be easily achieved. Given the economic and political constraints of many educational institutions, a program that does not require an exclusive, definitive corn-

Edmund.~m, and M o m ~ l

82

mitment is one that is more likely to receive administrative and individual support. To this end, participants were not required to adopt the entire set of strategies or materials presented at this conference. The re/at/re advantage feature refers to the favorable comparison of a new program to the previous and current approaches. For example, if the materials and strategies on building resiliency skills are user-friendly, developed from the latest research findings, and offer innovative approaches to the daily challenges of working with children growing up in dysfunctional families, these strategies are more likely to be selected over competing program~ found lacking in these areas. Content and skill-building strategies that are compl~ or difficult to understand and therefore communicate to others, are less likely to be adopted. When evaluating the extent of adoption, it is crucial to determine whether the audience understands the content of the training. Additionally, the audience must feel confident that they can implement the strategies they have learned and that they can effectively communicate this information to their colleagues. Cost-efficiency denotes the concept that perceived benefits of a new program must outweigh the costs of that program. Criteria for evaluating the cost-efficiency of this approach include; a) relative ease of use, b) effectiveness in working with students, and c) potential to satisfy any state-mandated or district policies for alcohol and drug education programs. For example, most participating schools used their local Drug-Free Schools money to hire substitutes and to cover the cost of registration. The final feature of successful diffusion efforts described by Orlandi et al. (1990) is low risk. Prevention strategies that are easy to justify, noncontroversial, and do not place the adopter at risk for job performance criticism are more likely to be adopted. Educators and institutional support staff who are motivated to implement an innovative alcohol and drug education prevention program will also require assurance of the quality of the program and local administrative support before the adoption becomes successful.

Implementation The third stage in the diffusion process is implementation. For this training, implementation refers to applying the seminar information with children or sharing it with colleagues. Implementation was promoted in several ways. First, the importance of sharing the information was stressed during the conference. Second, six copies of a summary of "learning points" (one copy for the conference participant and five copies for the participant

I;'-nhanChllgAdoption of an Alcohol Abuse Prevention Program

83

to share with colleagues) were distributed to each participant. Participants were encouraged to use the summary sheets with their students and to share the extra copies with colleagues. It was thought that the summary sheets would facilitate accurate and thorough communication. Maintenance The final stage of diffusion is program maintenance or institutionalization. Far too often this critical stage is overlooked in health promotion programs (Best, 1989). Admittedly, the time and funding constraints of the grant precluded extensive efforts to address maintenance issues related to this program. However, a variety of strategies can be used to sustain program implementation. Examples of strategies that can be employed include the use of reminders, continued (but limited) support from the sponsoring agency (e.g., resource lists or free/low cost materials), a supportive infrastructure, practice/familiarity with the program, goal setting among program participants, and the ability of the program to meet state or local mandates. Potential System Failure Points In addition to planning for each of the four stages of diffusion, Orlandi et. al. (1990) also identified potential barriers or system failure points that must also be addressed. Potential barriers related to the innovation itself, or to the dissemination, adoption, implementation or maintenance phases could negatively affect the diffusion process. For example, an innovation failure could occur if the product, in this case, an educational program, were unable to produce the results it had claimed. This could happen if the program was designed poorly, misrepresented or evaluated as inadequate. A communication failure could preclude the information from accurately and persuasively reaching the target audience. Examples of communication failure include: a) programs with vague/ambiguous content which could lead to a misunderstanding of the information, or b) an inadequate delivery system for the information. Additionally, it's critical to involve the user/adopter in the development of a program. This approach can mirfimize the gaps in translating research findings into practice and maximize a sense of program ownership. Even standardized prevention programs can be designed to facilitate user involvement. For example, all conference participants received a Connections Kit containing a resiliency building handbook, audiovisual materials, teaching guide and posters developed by the USDE. While the materials and resources in this kit were founded on the latest findings in alcoholism and

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Latin, Edmundson, and M o o r e - ~ !

educational research, the suggested strategies allow for individual input and local tailoring of activities. Therefore, this local tailoring ability should increase the likelihood of successful adoption.

RESULTS In addition to assessing diffusion in the above described qualitative manner, quantitative data were collected from the participants. To avoid an inordinately long questionnaire, only five of the features identified by Orlandi et al. (1990) were assessed in the first year. In particular, empirical data were collected to evaluate two adoption feature components (i.e., complexity and compaffoility), the degree of implementation, and two potential systems failure components (innovation and communication). To this end, a preconference questionnaire, a postconference questionnaire, and a followup questionnaire were administered to all conference participants. Before the pre- and postconference questionnaires were distributed, participants were given a brief explanation and assured that their responses were voluntary and confidential. (A six digit code provided by the participants allowed the researchers to match the pre-and postconference questionnaires while maintaining confidentiality of the responses). Participants completed both questionnaires in the room where the trainings were held. The followup questionnaire was mailed to the participants approximately two to four months after the conference. Description of the Questionnaires

The preconference questionnaire contained a 30 item knowledge measure designed to assess participants' preconference knowledge concerning CoA issues, and a 16 item drug attitude scale. Knowledge items (20 multiple choice and 10 true/false items) were written by the researchers based upon the information that would be presented to the participants. The items encompassed information from the four major areas of the training outline. Drug attitude items were designed to assess the respondent's attitude toward the use of drugs and alcohol. An example of an item is "It is all right to use alcohol to have a good time." Participants indicated their response on a five point scale anchored from 1 strongly agree to 5 strongly disagree. A copy of this instrument is included in Appendix A. The postconference questionnaire contained the same knowledge and drug attitude measures as the preconference questionnaire. In addition, participants assessed the seminar quality and provided background demo-

Enhancing Adoption of an Alcohol Abase Prevention Program

85

graphic information. Seminar quality was measured with nine items in which participants rated their responses on a 5-point Likert-type response scale from 1 strongty disagree to 5 strongly agree. Demographic information that was collected included: (a) whether the participant considered him/herself to be a CoA; (b) grade levels of the children with whom the participant interacted; (e) sex; (d) age; (e) eta'rent occupational position; (f) race; (g) religious denomination; (h) frequency of religious attendance; (i) number of children; and (.j) marital status. Finally, the extent to which the participants actually followed through with the request to share/apply the information was evaluated via questionnaires that the participants were asked to return to the researchers. Approximately two to four months after the seminar, all participants were mailed a postage-paid postcard and a letter explaining the reason for the follow-up evaluation. The follow-up questionnaire, printed on a postcard, simply asked the participant to indicate the number of persons with whom she or he had shared the conference information, and provided a place for the participant to write comments. Thus, the follow-up questionnaire provided a rough estimate of the number of persons with whom the information had been implemented with both children and colleagues.

Demographic Characteristics of Participants Table 1 presents the results of the demographic information reported by participants at the six conference sites. A total of 897 persons attended the conferences; 663 completed the pre- and postconference questionnaires. This 73.9% response rate is considered to be respectable and an accurate representation of the conference participants. Note that for some items, totals exceed 100%. This is because participants were encouraged to check all applicable response categories. Mean age of the conference participants was 40.5 years (SD = 8.9), and ranged from 20.0 to 68.0 years. Table 1 presents several interesting characteristics of the conference participants. First, educators from a wide range of employment settings attended the conference. Second, the vast majority of the participants were female, and third, nearly all of the participants were white. Finally, over one-third of the participants identified themselves as ACoAs. This is considerably higher than the ACoA rate of the general population, which is estimated by the National Clearinghouse for Alcohol and Drug Information to be roughly 11%. Such a discrepancy between the ACoA rates in the general population and the conference participants may be explained by: (a) the anecdotal evidence of persons in the "helping professions" having higher rates of alcoholism and other dysfunction in their families, and (b)

86

l.aflln, Edmunthen, and M o e r e - ~ l Table 1. Summary of Conference Participant Demographic Information N

% Answering "Yes"

177 109 19 50 10 46 84 37 24 95 95

26.7 16.4 2.9 7.5 1.5 6.9 12.7 5.6 3.6 14.3 14.3

Female Male

516 97

84.3 15.8

Race White Black Asian Hispanic Other

589 25 1 4 73

93.3 4.0 .2 .6 1.9

165 315 16 56 73

26.4 50.4 2.6 9.0 11.7

Marital Status Single Married Separated Divorced Widowed

100 431 13 71 12

15.9 68.7 2.1 11.3 1.9

Number of Children No children One child Two children Three children Four or more children

162 92 200 98 69

26.1 14.8 32.2 15.8 11.1

Self-Identification as CoA Identified as CoA Did. not identify as CoA

208 359

36.7 63.3

Current Occupational Position O a ~ ' o o m teacher School counselor School administrator Drug-free schools coordinator DARE officer Social worker Sutntance abuse coun~lor Nurse Other drug program administrator Other drug program coordinator Other Gender

Religious Denomination Catholic Protestant Jewish No Preference Other

Note. Some totals exceed 100% due to participants checking more than one

response category.

Enhancing Adoption of an Alcohol Abuse Prevention Program

87

greater motivation and interest on the part of adult CoAs to help young CoAs who are currently living with an addicted parent.

Adoption To assess complexity, the difference in CoA knowledge scores were examined between the pro- and posttest questionnaires. "l~ble 2 presents the results of the pro- and posttraining CoA knowledge scores. Scores are out of 30 poss~le points. As expected, the scores increased significantly from the pre- to the posttest (t = 38.19, p < .0001), indicating that the informarion was not too complex for the participants to understand and retain. Compatibility was assessed by investigating drug attitudes. "I~ble 3 presents the pre- and posttests means, standard deviations, minimum and maximum scale values, and internal consistency (coefficient alpha) estimates. Unlike CoA knowledge which did increase as a result of the conference, drug attitudes, as measured by this scale, did not change as a result of conference attendance (t = .161 p = .872). Furthermore, the mean item value of 2.26 represents a rating between the scale anchors of "disagree" and "neither agree nor disagree." Although it cannot be assumed that all respondents use the anchors of the scale in the same manner, this value indicates that the typical respondent possessed a moderately conservative attitude toward the use of alcohol and drugs. Given that the seminar information was also moderately conservative in its approach, these results Table 2. Descriptive Statistics for CoA Knowledge Measure Mean

SD

Minimum

Maximum

Pretest

16.65

3.32

0

27

Posttest

21.64

3.36

0

29

Note. Posttest scores are significantly higher than the pretest ~ r e s ; t = 38.19, p < .0001.

Table 3, Descriptive Statistics for Drug Attitude Questionnaire Mean

SD

Minimum

Maximum

Alpha

Pretest

2.26

.582

1.0

4.31

.83

Posttest

2.26

.561

1.0

4.37

.85

Note. Participants rated each item on a 5 point scale anchored from 1 strongly d/sagree to 5 strongly agree. The difference between the pre- and posttest means is not statistically significant; t -- .161, p = .872.

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Laflin, Edmund~m, and Moore-Hlrsc~

suggest that the seminar information was compatible with the value system of the average respondent.

Implementation Another important feature of this program was dissemination of the information beyond those directly trained at the seminar. Specifically, seminar participants were asked during the training to discuss and/or utilize what they learned with at least five others. Compliance with this request would therefore result in an additional 4,485 persons receiving at least some of the information (5 x 897 = 4,485). Although this approach may appear similar to the trainer-of-trainer model, it differs in three essential ways. First, instead of attempting to select (with vazying degrees of success) only a few, hand-picked "gatekeepers" to attend the trainings (as in the trainer-of-trainer model), thousands of frontrine educators were mailed brochures and invited to attend. In this way, important gatekeepers were self-identified, and the possibility of omitting key personnel from the trainings was minimized. Second, conference participants did not receive any training regarding basic presentation skills. It was the position of the authors that, as educators, most of these individuals already possessed adequate presentation skills and that they would not benefit from this type of training. Third, it was also not expected that the participants would become "experts" in the field of chemical dependency or resiliency building after a one day training. The training was not designed to prepare these educators for formal, in-depth presentations of the material. Instead, the aim of the training was for participants to add to their existing knowledge and skill base, and to leave with resources (e.g., summary of major points, lists of strategies to use in the work setting, research summaries of resilient children), an improved understanding of the major issues, and several concrete strategies to be implemented in their work setting. To assess compliance with the request to share the information with at least five others, questionnaires with return postage were included with the reminder letter. The questionnaire asked respondents to check one of three boxes: (a) had shared the information with no one; (b) had shared the information with only (fill in number) of persons; or (c) had shared the information with 5 others. The postcard also contained a place for participants to write comments. Inspection of the returned questionnaires revealed that many of the participants had shared the information with more than the requested five persons. Some participants specified a precise number, while others, by their comments, implied more than five (e.g., "shared the information with all kindergarten through 6th grade teachers and my

Enhancing Adoption of an Alcohol Abuse Prevention Program

89

Alateen group"). Thus, the questionnaires were divided into five groups: (a) those who had not shared the information with anyone; (b) those who had shared the information with one to four persons; (c) those who had shared the information with five persons only; (d) those who had shared the information with more than five, but did not report the specific number of persons with whom they had shared the information; and (e) those who reported a specific number of persons (greater than five) with whom they had shared the information. "lhble 4 presents the results from the questionnaire follow-up by these five groups. "Number of participants" (and the respective percent of total) refers to the number of respondents in a particular category. "Number of persons reached" (and respective percentage) refers to a lower bound estimate of the number of persons with whom the participants in a given category shared the information. Several points from this table merit further comment. First, very few of the respondents indicated that they had shared the information with no one (3.4%). While it is recognized that the more enthusiastic participant would be more likely to respond to the questionnaire follow-up, it should be noted that the response rate to the follow-up was 42.6%. While we would have hoped for a higher response rate, using only one contact atTable 4. Number of Persons with Whom Participants Shared Seminar Information: Postcard Follow-Up

Persons Category

Number of Participants and (%)

Number of Reached and (%)

Did not share with anyone

13 (3.4%)

0 (0.0%)

Shared with 1-4 persons

49 (12.8%)

141 (2.7%)

Shared with 5 persons

238 (62.3%)

1,190 (23.1%)

Shared with more than 5 but did not indicate specific number

41 (10.7%)

205+ (3.9%+)

Shared with more than 5 persons; number specified

41 (10.7%)

3,609 (70.1%)

Total

382 ++ (99.9%)

5,145+

(99.9%) Mean number of persons shared per participant

13.46+

Note. Total percentages do not add to 100% due to rounding. + indicates that this is a lower bound estimate. + + indicates that 382 returned postcards represent a 42.6% response rate.

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Laflln, Edmundson, and Moor~Hlrschl

tempt lowered the potential response rate. Second, in the last response category (shared with more than 5, number specified) the number of persons with whom these participants had shared the information ranged from 7 to over 1000 persons. The mean number stated was 90.2 and the median was 30. Also, these participants, while comprising only 10.7% of the follow-up respondents, were respons~le for reaching 70.14% of the persons receiving the information. (Such a difference is due to a few respondents stating that they had reached over 1000 persons). It is encouraging to note that over 83% of the respondents did comply with the request to reach at least 5 other persons. Finally, at least 5,145 additional people received the information from a conference participant (recall that the projected number was 4,485), resulting in a mean of 13.46 persons per participant. Such enthusiastic compliance with the request to share the information would seem to indicate that not only did participants find the information useful, but they also found it easy to share. In addition to the quantitative data, many comments from the followup questionnaire reflected participants' attitudes toward adoption, implementation, and maintenance of the seminar information. Of the 382 returned follow-up evaluation postcards, 241 (63%) contained comments. Because many comments could not exclusively be categorized as speaking only to the respondent's commitment to adopt, implement, or maintain the information, the comments were also organized in terms of numbers of persons with whom the participant had implemented the information. In addition to these five aforementioned groups of respondents, a sixth category of "negative responses" was created. It should be noted that of the 241 comments received, only 6 were negative. Although the comments were quite varied, 3 general types of comments emerged. The vast majority of comments simply praised the conference for its quality and usefulness. Many of the comments indicated that the participant planned to continue to implement the information in the future. Specifically, 87 of the 382 respondents (22.77%) stated such plans. Potential System Failure Points The participants' global evaluation of the seminar was another area of interest to the authors. As described above, it was posited that a favorable evaluation of the seminar was a necessary, but not sufficient condition for program adoption. That is, it was hypothesized that innovation failure and communication failure would occur if the participants' global evaluation of the seminar were poor. (Note that these dimensions are related to several of the adoption feature components, in particular complexity; that is, if the

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91

Table $. Summary of Responses to Seminar Evaluation Items Item

Mean

SD

1. After taking this seminar, I better understand the problems of children of alcoholics.

4.31

.623

2. Dr. Aekerman explained things clearly.

4.47

.649

3. The information in the seminar should be taught to all teachers.

4.49

.660

4. Important questions I had about children of alcoholics were answered in the seminar.

3.97

.748

5. The material presented in this seminar will be of use to me.

4.46

.687

6. As a result of this seminar, I believe that I will be more effective in handling the problems of children of alcoholics.

4.27

.693

7. The seminar was a waste of time. (Reverse scored)

4.75

.692

8. I would recommend that other people attend this seminar.

4.49

.676

9. I will share the information I learned in this seminar with at least five (5) other people.

4.55

.694

4.41

.673

Mean item response

Note. Participants rated each item on a 5 point scale, from (1) strongly disagree to (5) strongly agree.; Alpha = .875.

information is too complex, communication failure will occur). Accordingly, the postconference questionnaire contained a 9-item scale (coef. alpha = .875) designed to assess general satisfaction with the training. Table 5 presents the average item ratings (rated on a 5 point response scale from 1 strongly disagree to 5 strongly agree) and standard deviation for each of the 9 items. These average item ratings indicate very high satisfaction with the conference in all areas assessed.

DISCUSSION

This paper described the development and implementation of a seminar designed to train education professionals concerning common problems and experiences of children living with an addicted parent, and in strategies designed to mitigate the effects of living in such an environment. As discussed earlier, diffusion theory (Rogers, 1983) was used to develop and

F_~Imn~dl~o~ lnd Moore-il~Ir~:bl

assess the marketing of the trainings, the actual training itself, and the organizational impact of the trainings beyond the end of the day-long seminar. Practitioners can use the findings of this study to enhance their efforts in these three stages. In Stage 1, dissemination, several strategies were utilized to reach a wide variety of educators and to attract these educators to the seminars. These included using highly access~le and convenient locatious, incorporating attractive features into the seminar (e.g., CEU credits, low cost, lunch, and free resource materials), and using an internationally recognized presenter. Results indicated that educators from a wide range of employment settings attended the conference and, therefore, the trainings were successfully disseminated. Stage 2, adoption, was addressed in a variety of ways. As the results indicated, participants found the seminar information to be easy to understand and compatible with their value systems. The program materials were also designed to be flexible, to the extent that they allowed participants to select the features of the seminar that most effectively served their needs. The materials were also low in both financial and personal cost, and also low in risk. Because the literature indicates that practitioners would better serve this population through the implementation of resiliency skill building programs than through the identification of CoAs, the seminar targeted increasing participants' resiliency building strategies as opposed to teaching methods by which they could identify CoAs in their work settings. While support groups may be helpful for some students, the unintended outcomes of labeling students could be counterproductive to the program goals. Middle school teachers perceive building resiliency among all students as more within their natural domains and lower in risk (according to diffusion theory) than identification and referral of CoAS. Tune and cost limitations precluded formal measurement of other features of successfully diffused programs, such as flexibility, reversibility, relative advantage, cost-effciency, and risk. The inclusion of measures of compatibility and complexity and particular measures of efficacy, such as knowledge increase, were a requirement of the funding agency. After demonstrating evidence of success in these characteristics, additional features of successfully diffused programs will be studied in the next stage of the research. The low follow-up response rate creates limitations in assessing the diffusion of this project. Although over 83% of the respondents to this follow-up reported diffusing this information to at least 5 others, the response rate to this instrument was only 42.6%. A conservative lower boundary estimate of dissemination for the study population, assuming zero dissemination among the non-respondents, would result in a 35.7% compliance rate. Given the favorable evaluations of the conference, we expect actual compliance to be higher than this conservative estimate. Among respondents, over 83% corn-

Enhancing Adoption of a n

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plied with the request to implement the information with at least 5 other persons. According to the data supplied by the respondents, this information was di~minated to over 5,100 persons. Participant di.~emination of the information was aided by distn~outing six copies of the learning points to each conference participant. Although the fourth stage, maintenance, was not directly assessed with the evaluation instruments, comments on many of the follow-up questionnaires indicated participants' plans to continue utilizing the information. This information appears to lend itself well to use and dissemination by practitioners at all levels. Last, it was hypothesized that innovation and communication failures would result if the participants evaluated the conference to be poor in quality. The post conference results indicated general high satisfaction for all areas assessed. Comments on follow-up postcards lend further support to this conclusion. Changes Made for the Year 2 CoA Trainings

Even though all evaluation indices indicated that the trainings were highly successful, several changes have been planned for next year's evaluation of the trainings. As before, pre-post- and follow-up conference questionnaires will be used to assess the trainings. An additional modification of the instruments is the more direct measurement of the adoption phase components on the postconference questionnaire. That is, the seven components that have been found to facilitate adoption (compatibility, flexibility, reversibility, relative advantage, complexity, cost-efficiency, and r/sk) will be assessed with items developed specifically to measure these constructs. In a more direct test of diffusion theory, participants' evaluation of the conference on these adoption phase dimensions will be examined in relation to subsequent implementation of the information. Second, the implementation phase will be divided. In all evaluation instruments, a distinction will be made between implementing the information via informing interested colleagues and other professional, and implementing the information via app~ing the content with children and adolescents. Thus, evaluation of the degree of implementation at these two levels will be possible. Because informing others is likely to have a greater impact on the social and institutional infrastructure, assessment of this nature is important. Sharing the information with colleagues may have the added benefit of enhancing the participants' understanding of and commitment to the information. Last, during the final hour of the seminar, participants will be asked to complete an "action plan." This plan will ask participants to set both

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Laflin, Edmundson, and Moore-Hlrschl

information sharing and application goals, using concrete strategies to facilitate completion of both types of goals. "lliplicate copies of the participant's plan will be made. The grant researchers will retain the first copy, and the participant will keep the second. The third copy of the plan will be mailed to the participant six weeks following the training so that the participant can evaluate the degree to which he or she has completed his or her goals. Research from the area of goal setting (Locke & Latham, 1990) suggests that goals which are concrete, personalized, accepted, and moderately difficult are more likely to be completed than goals without these characteristics. Personalized goals also allow for greater flexibility, thereby enhancing the adoption phase of the conference. Moreover, such a follow-up will serve as a reminder of the importance of implementation and maintenance of the program information. Thus, completion of the action plan should assist participants in the adoption, implementation, and maintenance phases of diffusion theory.

REFERENCES Backer, T. E., Rogers, E. M., and Sopory, P. (1992). Designing Health Communication Campaigns: What Works? Sage Publications, Newbury Park, CA. Bangert-Drowns, R. L (1988). The effects of school based substance abuse education: a recta-analysis. Journal of Drug Education, 18, 243-264. Bernard, B. (1991). Fostering Res'dience in Kids: Protective Factors in the Family, School and Community. Northwest Regional Educational Laboratory, Portland, OR. Best, J. A. (1989). Intervention perspectives on school health promotion research. Health Education Quarterly, 16(2), 299-306. Bloom, P. N. and Novelli, W. D. (1981). Problems and challenges in social marketing. Journal of Marketing 45, 79-88. Brandon, P. R. (1992). State-level evaluations of school programs funded under the drug-free schools and communities act. Journal of Drug Education, 22(1), 25-36. Burk, J. P. and Sher, K. J. (1988). The "forgotten children" revisited: neglected areas of CoA research. Clinical Psychology Review, 8s 285-302. Burk, J. P. and Sher, K. J. (1990). Labeling the child of an alcoholic: Negative stereotyping by mental health professionals and peers. Journal of Studies on Akoho~ 51(2), 156-163. Ewart, C. K. (1991). Social action theory for a public health psychology. American Psychologist, 46(9), 931-946. Hansen, W. B. (1992). School-based substance abuse prevention: a review of the state of the art in curriculum, 1980-1990. Health Education Research, Theory and Practice, 7(3), 403.430. Knight, S. M., Vail-Smith, K. and Barnes, A. M. (1992). Children of alcoholics in the classroom: A survey of teacher perceptions and training needs. Journal of School Health, 62(8), 367-371. Locke, E. A. & Latham, G. P. (1990). A Theory of Goal Setting and Task Performance. Prentice Hall, Englewood Cliffs, N'J. Orlandi, M., Landers, C., Weston, R. and Haley, N. (1990). Diffusion of health promotion innovations. In Glanz, Lewis and Rimer (eds), Health Behavior and Health Education. Jossey-Bass Publishing, San Francisco, p. 288-313. Rogers, E. M. (1983). Diffusion of Innovations. Free Press, New York.

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Roosa, M. W., Beah, J., Sander, L N., and Pillow, D. R. (1990). The role of risk and protective factors in predicting symptomatology in adolescent children of alcoholics. Amer/can Journa/of Commun/ty Psycho/og),, 18(5), 725-741. Roosa, M. W., Gensheimer, L, IL, Ayers, T. S, and Short, J. L. (1990). Development of a school-based prevention program for children in alcoholic families. Journal of Primary Ptwent/on, 11(2), 119-141. Sher, K. J., Walitzer, IC S., Wood, P. K. and Brent, E. E. (1991). Characteristics of children of alcoholics: putative risk factors, substance abuse and psychology. 1ournal of Abnormal

es~hot~, 100(4), 427-448. Tharinger, D. J. & Koranek, M. E. (1988). Children of alcoholics--at risk an unserved: a review of research and service roles for school psychologists. Schoo/Psycho/ogy Rev/ew, 17(1), 166-191. Wallerstein, N. (1992). Powerlessness, empowerment, and health: Implications for health promotion programs. Amer/can Journal of Health Promotion, 6(3), 197-205. Werner, E, E. (1986). Resilient offspring of alcoholics: a longitudinal study from birth to age 18. Journal of Sn_,d_~_ on Alcohol, 47, 34-40. West, M.O. & Prinz, R.J. (1987). Parental Alcoholism and childhood psychopathology.

esychoto~.at Bu/tean, 102(2), 204-218. Woodside, M. (1988). Research on children of alcoholics: Past and future. British Journal of

Addiction, 83, 785-792.

APPENDIX The Children of Alcoholics Program (pre-seminar) DO N O T WRITE YOUR NAME on this questionnaire. The first three items in Part III of the survey will be used to establish a code number for your questionnaire. Your answers will remain anonymous and no effort will be made to personally identify your answers. In view of the anonymous nature of this questionnaire, please feel assured that you may respond with the utmost frankness. Your participation in this project is strictly voluntary. The items in this questionnaire deal with your general background, your occupation, your beliefs about and attitudes toward drug use, and your knowledge about children of alcoholics. We ask you to provide some information of a personal nature. This is the reason for your answering anonymously and for the use of a code number which protects your identity. You may refuse to respond to this questionnaire, and your decision will not influence you in any way. It will have no influence on your employment or on your participation in this educational seminar. If you wish, you may also decline to answer particular questions. Several of the questions will be asked both before the seminar has begun and after the seminar has been completed. This is necessary to assess possible changes in knowledge, attitudes, and beliefs. Although you may feel uncomfortable answering knowledge questions, particularly before you have been exposed to the seminar materials, the government requires such

96

L~

Edmund~m, and Moore-Hire.hi

assessments to gauge the effectiveness of these seminars. Without such cAdence, they will not give further grants allowing us to offer programs at such a low cost. While your participation is volunta_,y, we would like to ask you to cooperate in this study. This is one of the first studies which has attempted to assess the outcomes of programs designed to train school personnel about substance abuse. Your participation will contn'bute to a better understanding of the factors associated with effective training of school personnel. We thank you for your cooperation and assure you that your participation is strictly confidential. Molly Lafiln, Ph.D. Project Director Elizabeth Edmundson, Ph.D. Director of Evaluation Debra S. Schroeder, M.A. Bob E. Hayes, M.A. Research Assistants

Part I

Please answer the following questions by placing a checkmark in the "T" column if you think the statement is true, and in the "F column if you think the statement is false. Even if you are unsure, make a guess. We do not expect you to answer all questions correctly. Your responses will help us make any changes necessary to effectively communicate the material in future seminars. T

F

[]

[]

[]

[]

[]

[]

1. Most children of alcoholics can be labeled as having a conduct (i.e., behavior) disorder. 2. Children of alcoholics tend to be affected in the same way by parental alcoholism. 3. For both boys and girls, more negative effects are seen when both parents are alcoholics than when one parent is an alcoholic.

Enlumcing Adoption of an Alcohol Abuse Prevention Program

97

[][]

4. Teachers typically have the skills to counsel children of alco-

[][]

5. Children of alcoholics are more likely to be sexually abused

[][]

6. Children whose alcoholic parents become passive after a drink-

holics.

than are children of non-alcoholics.

[]

[]

[]

[]

[]

[]

[]

[]

[]

[]

[]

[]

[] []

[] []

[]

[]

[]

[]

[]

[]

[]

[]

[]

[]

[]

[]

ing episode are less negatively affected than are children whose parents become abusive. 7. Children of alcoholics tend to believe they are powerless in controlLing their parents' drinking. 8. Research has indicated that children from different cultures are affected in the same way by parental alcoholism. 9. A healthy sense of humor is a characteristic of children who are resilient to (i.e., who are able to cope with) the effects of an alcoholic parent. 10. The achiever, the detacher and the vulnerable are typologies (i.e., categories) that describe adult children of alcoholics and co-dependents. 11. People with a same-sex alcoholic parent are more likely to become alcoholics than are those with an other-sex alcoholic parent. 12. Children of alcoholics resent their alcoholic parent and not their non-alcoholic parent. 13. Most children of alcoholics become alcoholics themselves. 14. Evidence supports that there are four roles of children of alcoholics: the mascot, the lost child, the family hero, and the scapegoat. 15. Teachers should communicate to children of alcoholics that their (the children's) difficulties are due to their parents' alcoholism. 16. Giving examples in class that closely mirror a specific child's problems--without disclosing any names--can help establish trust with that child. 17. Role plays are effective strategies to use in helping students develop refusal skills. 18. If a student becomes agitated and talkative during a discussion on alcohol, it is more effective to move on to another topic and discuss this issue one-on-one with the student. 19. Children of alcoholics tend to live in home environments that have many rituals and routines. 20. Children of alcoholics are considered resilient (i.e., effective copers) when they get good grades.

Iatflln, Edmundsm, and Moere-Hlrsehl

98

Multiple Choice Items Please answer the following questions by circling the correct answer. 1. Approximately what percentage of children of alcoholics can be labeled as having a conduct (i.e., behavior) disorder? 1) 3% 2) 20%

3) 65% 4) so% 2. Which of the following psychological theories is most useful in understanding the age-inappropriate behavior of many children of alcohofics? 1) behavioral theories 2) social learning theories 3) psychoanalytic theories 4) developmental stage theories 3. Which of the following factors are important in determining how the parent's alcoholism affects the child? 1) the severity of the parent's alcoholism 2) the behavior of the drunk alcoholic parent 3) the size of the immediate family 4) both a and b 5) all the above 4. A son is most psychologically harmed by alcoholism w h e n . . . 1) the father is alcoholic 2) the mother is alcoholic 3) both parents are alcoholic 5. Which of the following things should you, as a teacher, n o t do with children of alcoholics? 1) tell the children that their difficulties are because of the parents' alcoholism 2) show the children you are trustworthy 3) encourage the children to express their feelings 4) all the above are helpful things to do 6. Which of the following typologies (i.e., categories) represents the best-adjusted adult child of an alcoholic? 1) the achiever 2) the other-directed one

Enhancing Adeption of

an

AlcoholAbuse Prevention Program

99

3) the triangulator 4) the invulnerable 7. One effective method an educator can use to address a child's internal conflict is to: 1) help the child to recognize situations in which taking no action may be the best response 2) encourage the child to confront the alcoholic parent when he/ she is inconsistent in his/her demands 3) request a review to determine if the child should be removed from the home 4) have the child stay after school for a one-on-one assessment of the problem 8. If a child asks you, "What can I do?" about a parent's drinking problem, you should suggest that the child should: 1) get involved in doing something fun at school or elsewhere, such as the school band, a softball team, or the Boy or Girl Scouts 2) try to convince his/her parents to stop drinking 3) pour out or water down the alcohol at home 4) all of the above 9. Children of alcoholics are considered resilient (i.e., effective copers) when they: 1) approach new experiences with confidence 2) stubbornly resist being the center of attention 3) take a passive role in solving their problems 4) demonstrate academic excellence 1O. Resiliency (i.e., effective coping) is demonstrated by 1) exposure to serious psychological or physical abuse 2) delayed emotional maturity 3) the ability to navigate difficult times without serious psychological damage 4) learning that children don't really have any control over their lives Part H Indicate the extent to which you agree or disagree with each of the following statements. Place your answers to the left of each question. Use the scale below:

100

IadUn, Edmumison, and Moore-HirscM

Strongly Disagree 1

_ _

_ _

Disagree 2

Neither agree nor disagree 3

Agree 4

Strongly Agree 5

1. There is nothing wrong with marijuana other than the fact that it is illegal. 2. It is all fight to use alcohol to have a good time. 3. If you use illegal drugs, you ought to go to jail. 4. It is all fight to use marijuana. 5. People should never use illegal drugs. 6. Marijuana is okay if used in moderation. 7. It is okay for someone to get drunk every once in a while. 8. People who use marijuana are fools. 9. Using drugs is immoral as well as illegal. 10. We need stricter laws to control drugs. 11. People who use cocaine are stupid. 12. Getting high on marijuana is a perfectly enjoyable experience. 13. It is okay to use drugs for kicks. 14. There is nothing wrong with marijuana. 15. It is fun to get high. 16. People who use illegal drugs are stupid. Part III

1. What are the last two numbers in the year you were born? 19___ __ 2. What are the last two numbers in your phone number? XXX-XX_ _ 3. What are the middle two numbers in your social security number? XXX-XXXX 4. How much are you looking forward to participating in the seminar? (Please circle one) Not at all

Somewhat

Fairly much

Very much

Completely

1

2

3

4

5

5. What made you decide to attend this seminar? (Check all that apply) 1. Continuing Education Units or Board Recognized Clock Hours 2. Nominated by school officials 3. Required to go by school officials __ 4. Problems in the classroom related to parental alcoholism or suspected parental alcoholism

Enhancing Adoption of an Alcohol Abuse l~r

Program

I01

5. Wanted to increase my knowledge about children of alcoholics 6. Reasonable Cost 7. Personal 8. Other 6. Have you ever attended a seminar by Robert Ackerman? (Please circle one)

Yes

No