An interdisciplinary team model for substance abuse prevention in communities

An Interdisciplinary Team Model for Substance Abuse Prevention in Communities MARIANNE T. MARCUS,

Recognizing the continuing threat of alcohol, tobacco, and other drug abuse and the mandate for health care reform with emphasis on communitybased care and prevention, the University of TexasHouston Health Science Center School of Nursing developed a model to link faculty to communities to provide culturally competent, scientifically based, preventive interventions. Faculty and community associates engaged in individual and group training activities such as seminars, courses, and off-site meetings. The Preventive Intervention Research Cycle was used to structure prevention activities and assure scientific rigor. In addition to the specific outcomes of five preventive interventions, the project resulted in increased faculty scholarship in the field, increased community awareness and sustained interventions related to substance abuse, enhanced curriculum for students, and expanded collaborations with other community-based organizations. Collaborative interdisciplinary partnerships between academic institutions and community organizations are critical to the development of the science of substance abuse prevention. (Index words: Substance abuse; Communitybased prevention; Faculty development; Interdisciplinary collaboration; Cultural competence) J Prof Nurs 16:158-168, 2000. Copyright © 2000 by W.B. Saunders Company

LCOHOL, TOBACCO, and other drug (ATOD) use and abuse continue to pose major threats to the health and safety of our communities. Substance abuse results in more deaths, illnesses, and disabilities than does any other preventable health problem. In this country, one in four deaths annually is attributable to alcohol, illicit drug, or tobacco use.,The safety of neighborhoods, homes, and workplaces is severely

*JohnP. McGovernProfessorm AddicuonNurs,ng, and Chair, Department of Nursing Systemsand Technology,Umversltyof Texas-HoustonHealth ScienceCenter, Houston,TX Supported by a Faculty Development Project Grant No. 1T15P07775 from the Center for SubstanceAbuse Prevention, SubstanceAbuseMentalHealth ServicesAdmmistrat*on Addresscorrespondenceand reprintrequeststo Dr Marcus:The Universityof Texas--Houston Health ScienceCenter School of Nursing, 1100 HolcombeBlvd,State5.518, Houston,TX 77030. Copyright© 2000 byWB SaundersCompany 8755-7223/00/1603-0011510.00/0 do,:10.1053/PN.2000.5920 158

EdD, RN, F A A N *

compromised by violence, accidents, and crime that result from substance abuse. A recent study by the National Center on Addictions and Substance Abuse revealed that drug and alcohol abuse are implicated in the incarceration of 80 per cent of the men and women behind bars in the United States (Behind Bars, 1998). In 1992, the economic cost of drug abuse to the United States was estimated to be $97.7 billion with a 12.5 per cent calculated increase to $109.8 billion in 1995 (NIDA Notes, 1998). No segment of society is immune. People of all ages, cultures, and socioeconomic groups experience substance misuse and abuse with some significant differences among the groups (Vasquez, 1998; Espinosa, 1998; Caetano, 1994; Caetano, 1995; Caetano & Hines, 1996; Caetano, 1997; Carr, Kennedy & Dimick, 1996; Hansen & Graham, 1991; Bates & Labouvie, 1997; Hawkins, Catalano & Miller, 1992; Heyman, 1996; Substance AbuseAmong OlderAdults, 1998; Tricker, 1996; Galin, 1998). As the American people have become more health conscious, there is growing intolerance to the problem of substance abuse and its many deleterious ramifications. Community receptivity for culturally competent, age-sensitive, and effective prevention and treatment programs is increasing. At the same time, in response to health care reform, care delivery is shifting to the community, with an emphasis on providing quality care at low cost through community-based organizations (CBOs) (O'Neil & Coffman, 1998). Primary care and prevention activities are key features in the school-, church-, and neighborhood-based clinics that typify CBOs. Nursing professionals, like other providers, are being exhorted to consider contextual factors related to health promotion and to engage in political activism to effect social change in communities (Morgan & Marsh, 1998; Bellack, 1998). It follows, then, that health care professionals must have expertise in the delivery of comprehensive ATOD prevention and treatment in the community. They must possess the ability to impart that information to others and to provide leadership within their specialues and their professions. Faculty development and

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correlated student education is critical to ensure that the related imperatives of expert ATOD prevention and community-based care thrive in today's health care arena. This article describes a successful interdisciplinary team model for developing faculty to deliver substance abuse prevention programs m CBOs. The model combines faculty development, student involvement, community participation, and implementation of preventive interventions. Although it specifically relates to the major public health concerns associated with ATOD use and abuse, the model is applicable to other health problems that may be expected to respond to community prevention programs. The model was developed and implemented with a 3-year grant from the Center for Substance Abuse Prevention (CSAP), Substance Abuse/Mental Health Services Administration (SAMHSA), but, like a previous model for curricular change, it can be applied in academic and community settings with more limited means (Marcus, 1997). Improving Nursing Competence in Substance Abuse Since 1983, The University of Texas Houston Health Science Center School of Nursing (UTHHSC-SON) has been engaged in activities to improve nursing competence related to caring for substance-abusing clients. Faculty and students responded to the need for a nurse-managed clinic at a residential facility in 1983 (Marcus, Gerace & Sullivan, 1996). An elective course on substance use and abuse was added to the curriculum in 1988. In 1990, the UTHHSC-SON was the recipient of a 5-year faculty development grant from CSAE.The first cohort of Faculty Fellows trained under the grant brought about the necessary curricular changes to infuse ATOD content and developed the Addictions Focus, an expansion of the Psychiatric Mental Health Nursing Graduate Track, to emphasize this subspedalty (Marcus, 1997). The Addictions Focus is now provided to two other schools of nursing in Texas by distributive education techniques. Subsequent private funding provided a collaborative continuing education program for hospital-based nurses within the University of Texas Medical Center and resulted in the publication of a reference manual for this group (Marcus, Rickman & Sobhan, 1999). Much progress occurred with these initiatives. By 1995, curricula were in place, and a first cohort of three faculty had individual dinical and research programs that reflected their ATOD development opportunities. The intense current and anticipated

future ATOD educational activities and the changing patterns of health care underscored the need for additional faculty to be prepared to deliver communitybased care that incorporates state-of-the-art prevention strategies. From this vantage point, the school responded to a CSAP announcement of funding for the development of a second cohort of Faculty Fellows who would establish community-based programs. This article describes the accomplishments of the second group of CSAP Faculty Fellows during the 3 years of the project ending in 1998. GOALS

Recognizing the continuing threat of ATOD use and abuse, the mandate for health care reform with emphasis on community-based primary care and prevention, and the intense level of substance abuse education at the UTHHSC-SON, the SON proposed to develop five Faculty Fellows who would extend and expand the work of the previous cohort, establish collaborative links to the community, and focus on the critical need for culturally sensitive ATOD use and abuse prevention. The specific goals of the project were to (1) develop a cadre of nursing faculty, representative of diverse clinical specialties, with the expertise necessary to deliver comprehensive services to prevent ATOD use and abuse and to impart those skdls to students and other professionals; (2) establish collaborative links with community-based professionals to develop, implement, and evaluate culturally competent and age- and gender-sensitive prevention programs; and (3) disseminate empirically based instructional and prevention materials that may be used by others in the field. Process CONCEPTUAL FRAMEWORKS

Several conceptual frameworks, definitions, and resources were selected to facilitate the project, assure scientific rigor, and support plans leading to goal attainment. They include the Mental Health Intervention Spectrum, a model for cultural competence, and a strategy for social influence resistance training. MENTAL HEALTH PREVENTION SPECTRUM

The Mental Health Intervention Spectrum (Mrazek & Haggerty, 1994) is a comprehensive model that incorporates prevention, treatment, and maintenance as it relates to mental health and substance abuse disorders (Fig 1). The prevention segments of the

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Treatment

Case Identification

Prevention

Indicated

Standard Treatment for Known Disorders

Maintenance

Compliance with Long-term Treatment (Goal: Reduction in Relapse and Recurrence)

Selective

Universal

After-care (Including Rehabilitation)

Fzgure1. The mental health intervennon spectrum. (Reprinted with permission from Reducing Risks for Mental Disorders: Frontiers for Preventative Intervention. Copyright (1994) by the National Academy of Sciences. Courtesy of the Nanonal Academy Press, Washington, DC.) spectrum, ie, universal, selective, and indicated, were the main focus of the project. However, Fellows also received training in the treatment and maintenance segments of the spectrum to provide a complete understanding of the phenomenon of substance abuse disorders. Treatment includes case identification and standard treatment for known disorders. The maintenance segments of the spectrum address compliance with long-term treatment, after-care, and rehabilitation. Preventive Intervention

The most frequently cited classification system of disease prevention, proposed by the Commission of Chronic Illness in 1957, identifies three types of prevention: primary, or that which seeks to decrease the number of new cases or incidence of disease; secondary, or activities that seek to lower the rate of established cases or prevalence of a disorder; and tertiary, which seeks to decrease disabilities associated with an existing disorder (Mrazek & Haggerty, 1994). This system implies an understanding of the relationship between causative factors and health outcomes. Since that classification was formulated, there is new appreciation for the complex interplay between and among environmental, intellectual, physical, psychological, social, and spiritual factors with health out-

comes. To be effective, preventive interventions must take into consideration these biopsychosocial factors. Hence, the preventive intervention model chosen for this project is that which is embedded in the Mental Health Intervention Spectrum, a disease model developed by Gordon (1983) and adapted for mental health by a committee of representatives from the National Institute of Medicine (Mrazek & Haggerty, 1994). At the heart of the model is the concept of risk reduction. Individuals are known to have risk and protective factors that mediate the potential for substance abuse. The critical first step in designing preventive interventions is to examine the interplay between biopsychosocial risk and protective factors in a given population to design strategies that will reduce risks and enhance protective factors. Universal preventwe interventions are those programs applicable to the general public. For example, nutrition or stress-reduction programs are cost effective, acceptable to all, and present a low risk to participants. A training program to increase social competence in school-aged children, thereby reducing the likelihood that they will respond to peer pressure, is an ATOD-related universal preventive intervention performed during the project (Bierman & Greenberg, 1996). Selective preventive interventions are targeted for individuals and subgroups of the population who

INTERDISCIPLINARY TEAM MODEL

16]

are at risk for developing the disorder. An example of a selective preventive intervention developed by one Faculty Fellow is a home visitation program for drug-exposed neonates and their families. Indicated preventive interventions are aimed at high-risk individuals who may have minimal but detectable signs or symptoms of the disorder. A group adherence program to facilitate after-care compliance of dually diagnosed individuals in the community, an indicated preventive intervention was designed and implemented by a Faculty Fellow. Preventive InterventionResearch Cycle There are many challenges to providing effective community-based preventive interventions. Such interventions must effectively manipulate the mediating variables in the direction of desired change, but often mediating variables are not well understood (Pathways of Addiction, 1996). Fellows were encouraged to meet these challenges and strive for scientific rigor within the framework of the preventive intervention research cycle outlined by Mrazek and Haggerty, 1994 (Fig 2). The cycle has five components. It was anticipated that the Fellows could accomplish the first three steps of the cycle during the 3-year time flame of the project. The first year was used to acquire necessary background education related to ATOD use, abuse, and prevention. This was also the time designated for establishing links with Community Associates, community-based professionals who would participate fully in the conduct of the intervention research. Toward the end of the first year, it was expected that

the research design would be ready for submission to the Committee for the Protection of Human Subjects, the institutional review board at the UTHHSC. The second and third year would see the implementation of the study and analysis of data. This timeline was met with varying degrees of success. Each Fellow established links to CBOs and designed collaborative preventive interventions with Community Associates. There were occasional hurdles to overcome. For example, school schedules did not always coincide with the university and the clinical practice responsibilities of the Fellows. Times for a school-based intervention had to be coordinated to circumvent these obstacles. In another instance, the CBO would not permit the designated Community Associate to participate without financial compensation. This was an isolated occurrence. Most agencies were pleased to be included in the project and made every effort to facilitate the collaborative research. Cultural Competence Awareness of cultural factors associated with ATOD use and abuse, as well as other health problems, is critical to understanding comprehensive prevention and treatment (Poss, 1999). According to Mrazek and Haggerty (1994), there is a clear link between cultural competence and the success or failure of preventive interventions. Wright and Watts (1985) note, for example, that approaching alcohol abuse among African American youth may start with some of the same elements as with other ethnic groups, but issues, such as high unemployment levels, pose additional risks for

Feedback Loop 1 Identify problem or disorder(s) and review informataon to determine ~ts extent

2 W~th an emphasis on risk and protectrve factors, rewew relevant fnformatlon - both from fields outstde preventton and from existing intervention research programs

3 Design, conduct, and analyze ptlot studtes and confirmatory and replication trials of the preventwe mterventton program

4 Design, conduct, and analyze large-scale trials of the preventwe intervention program

5 Faclhtate large-scale implementatton and ongoing evaluatton of the preventwe intervention program in the community

Figure2. Prevennon intervention research cycle. (Reprinted with permission from Reducing Risks for Mental Disorders: Fronners for Preventative Intervention. Copyright (1994) by the National Academy of Sciences. Courtesy of the National Academy Press, Washington, DC.)

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this group. On the other hand, understanding of the rich cultural history, with roots in Africa, is key to assisting African American youth to build the protective self-pride necessary to promote positive drinking behaviors. Gerstein and Green (1993) note the serious paradox that African Americans are far less likely than non-Hispanic whites to use drugs, but those who do are far more likely to become dysfunctional. Similarly, Hispanic drug use prevalence is lower than for nonHispanic whites overall, but Hispanics are overrepresented in drug-treatment and criminal justice statistics. The cultural competence model described by Campinha-Bacote (1991) guided Faculty Fellows in addressing cultural competence in their preventive interventions. The model is comprehensive, incorporating cultural awareness, cultural knowledge, cultural skills, and the cultural encounter or personal experience with the group. Dr. Campinha-Bacote was a consultant for the Fellows. She provided a workshop for all faculty, students, and community providers and reviewed proposed interventions for cultural competence. SOCIAL INFLUENCE RESISTANCE TRAINING

Programs to enhance social competence by improving impulse control and increasing conflict resolution skills have been found to be successful with schoolaged children and adolescents and are becoming cornerstones for prevention programs with these age groups (Hansen, 1992). One such program, "Say It Straight" (SIS), was used as part of the training experience of Faculty Fellows and their Community Associates. The intensive 4-day training was, in itself, a unique bonding experience for the group. SIS, developed by Paula Englander-Golden and the late Virginia Satir (Englander-Golden, Elconin & Satir, 1991), is a research-based communication training program that is used to enhance protective factors and reduce risk factors in individuals and systems. The training is action oriented, using visual, auditory, and kinesthetic modalities to meaningfully involve individuals with different learning styles. Participants become aware of their ability to "say it straight" in difficult situations and practice behaviors that honor their deepest yearnings without demeaning themselves or others. The training is used to prevent substance abuse and other destructive behaviors, m conflict management, negotiation, and relationship skills building, for marriage enhancement, to improve family communication and parenting skills, to reduce family conflict and domestic violence, and to promote stu-

dent-parent-school-community bonding and community networking (Englander-Golden, Elconin, Miller & Schwarzkopf, 1986a; Englander-Golden & Golden, 1996). Dr. Englander-Golden, a consultant to the project, conducted the training for Faculty Fellows and Community Associates and served as an advisor in two school-based settings where this strategy was implemented. SUBSTANCE ABUSE TREATMENT PROVIDERS

There are approximately 700 licensed substance abuse treatment programs in Texas. The project is located in Harris County where there are about 150 programs, a major Veteran's Administration Medical Center, seven psychiatric hospitals with chemical dependency programs, and 19 methadone programs. Publicly funded treatment in Texas has grown at an unprecedented rate. As the number of clients has grown, the need for qualified health professionals also has grown, and has created an urgent need to prepare faculty and students from the health disciplines to meet this challenge. In addition to the increase in community-based programs, landmark legislation, passed in 1991, created the Texas Criminal Justice Treatment Initiative, a comprehensive treatment system for substanceabusing offenders. The initiative is the largest such program in the United States. Prison treatment programs are important because so many incarcerated individuals are there owing to drug-related offences (Behind Bars, 1998). Houston and environs, owing to population density, have the highest single percentage of actual and projected treatment beds in the Criminal Jusnce Treatment Initiative. Fellows had access to this system. Under the aegis of UTHHSC, the UTHHSCSON has direct links with the chemical dependency programs at Harris County Psychiatric Center, the Substance Abuse Research Center of the Mental Sciences Institute, and the unique campus program at Houston Recovery Campus. Fellows chose from these and others of the rich array of treatment settings in the area to meet their educational needs.

Selected Commumty-BasedOrganizations An aim of the project was that Fellows and Community Associates from the CBOs work collaboratively to design and implement preventive interventions. Major emphasis was placed on assuring that CBOs acquire the necessary skills to continue prevention activities beyond the period of the project. Two

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examples of CBOs in which Fellows established links are K.I.N.D.E.R. (Kids and their families In Need of Drug Evaluation and Rehabilitation) Clinic and Carrillo Hementary School. K.I.N.D.E.R. Clinic is the only clinic in Harris County to provide specialized long-term primary health, social, and developmental services to children who have been exposed to substances in utero. K.I.N.D.E.R. Clinic was established in 1994 by Maria Ferris, MD, to fill a major gap in health services and to prevent substance-affected children from falling victim to medical neglect and, therefore, repeating the cycle of substance abuse. Since its inception, K.I.N.D.E.R. Climc has enrolled over 800 children (60 per cent African American, 19 per cent Caucasian, 20 per cent Hispanic, and 1 per cent other). The majority of these children are polydrug exposed, and 60 per cent remain in the custody of their biological mothers, who frequently relapse to substance abuse after their children are born. A pediatrician there became a Community Associate who collaborated with a Fellow, designing and implementing a homevisiting program for K.I.N.D.E.R. Clinic families. Carillo Hementary School, part of the Houston Independent School District, is located in a predominantly Hispanic community. Carrillo has a total enrollment of 816 students in prekindergarten through sixth grade. Ninety-seven per cent of the students are Hispanic, 2 per cent African American, 1 per cent Caucasian, and 1 per cent other. Sixty-four per cent of the children are in the bilingual program, and 5 per cent are special education students. Expanded health services, with a goal of moving toward integrated service, including prevention education, made this school receptive to participation in the project. Moreover, the community was experiencing an increase in gang activity and had expressed a need for prevention strategies to address that issue and the related problem of substance abuse. A community health faculty member, teamed with a Fellow, a Licensed Chemical Dependency Counselor, and teachers at Carrillo to provide bilingual training. Other CBOs selected for the project included the student health clinic on the downtown campus of the University of Houston, the counseling program for athletes on the main campus of the umversity, and an outpatient after-care program for dually diagnosed patients at the Harris County Psychiatric Center. In each instance, Community Associates participated in designing and providing appropriate preventive interventions.

FACULTY FELLOWS

The imperative was to develop Faculty Fellows from diverse clinical specialties because substance abuse touches all age groups and appears in all practice settings. In addition, this group of Fellows was to extend and expand the work of the previous cohort who had integrated substance abuse throughout the curriculum and designed the Addictions Focus graduate emphasis. Now the mission was to move beyond the walls of U T H S C to the community. Each Fellow was asked to identify a particular area or population for preventive intervention so that they could meet their goals in a timely manner. Several of those target populations changed over the course of the project because of a lack of community receptivity or the changing interests and level of preparation of the Fellows. As the Fellows became more sophisticated in their knowledge and skills related to substance abuse, they modified their individual objectives. Given that Faculty Fellows were expected to provide academic and clinical leadership for students, faculty, and the community, it was important, too, that they be doctorally prepared and credentialled for advance practice within their specialties, which included adult health, neonatal, pediatrics, psychiatric-mental health, and, gerontology. FACULTY EDUCATION: INDIVIDUAL AND GROUP

Faculty Fellows came to the project with varying levels of preparation in the field of addictive disorders. They identified their individual learning needs related to ATOD abuse, prevention, and treatment. Those needs ranged from basic information about the phenomenon of substance abuse to complex treatment approaches and prevention strategies. Activities for individual learning included attending specialty conferences according to their clinical area of interest, working with mentors within the Houston community, observing in treatment settings, acquiring skills with prevention techniques, and engaging in selfstudy. All of the Fellows attended the Betty Ford Professional in Residence program and found it a useful, intensive immersion experience (Pollack, 1997). Group learning activities included monthly seminars to discuss progress toward goal attainment and the latest information about ATOD abuse prevention and treatment. Seminar format varied, but included journal club presentations, skills demonstrations, guest speakers, and progress reports on preventive interventions. For example, one Fellow attended educational experiences on Rational Emotive Therapy (Hlis &

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Model

Harper, 1961). She brought this information back to the group and showed how the technique was used with substance-abusing clients. In the third year of the project, Fellows had abstracts of papers and presentations to discuss and critique during seminars. Community Associates were invited to participate in seminars and other group activities, such as "Say It Straight" training, toward the latter part of the first year of the project. A second important group learning activity was attending the annual conference of the Association of Medical Education and Research in Substance Abuse (AMERSA), a muhidisciplinary organization that focuses on improving education and practice in the substance abuse field. At AIVIERSA meetings, the Fellows acquired the latest ATOD information and met with Fellows from other programs around the country. During the second and third years, Community Associates were invited to AMERSA meetings. Faculty Fellows, Project Director, Evaluator, and Community Associates were represented each year among the paper and/or poster presentations. During the second and third years, the group also planned and participated in major conferences. One year, the focus was multidisciplinary solutions to the problems of substance use and abuse. Another year the conference focused on prevention and treatment needs of special populations. These meetings included nationally prominent speakers and workshops that provided skills training in prevention and treatment strategies. They attracted a muhidisciplinary audience of physicians, nurses, social workers, psychologists, and counselors and contributed to the goal of disseminating substance abuse information.

Establish Team

• •

Faculty Community S t u d e n t (s)

TEAMS

Teams were constituted according to the nature and purpose of the respective CBO, their membership varying to reflect the needs of the targeted population. Each team induded a Faculty Fellow, Community Associate(s), and student(s). The title Community Associate was given to key individuals in the agencies who became full partners on the projects. Community Associates were typically the gatekeepers to the CBOs and likely to sustain the interventions beyond the life of the project. They represented many disciplines, including physicians, social workers, counselors, teachers, and law enforcement officers. Community Associates attended educational activities at the SON, traveled to conferences, collaborated in the design and implementation of the preventive intervention and in the development of resultant presentations and publications. Many continue to enjoy close links to the SON by attending seminars and participating in student education. Students also became members of the team. Graduate students, in particular, engaged in thesis research

Define Target Population

• •

Associates •

The process of designing and implementing preventive interventions was guided by a model that was based on previously defined conceptual frameworks and community resources (Fig 3). Fellows explored the needs of various CBOs and began to establish linkages with agencies according to their clinical specialties. The first step in the model was to establish the team.

Identity P r o b l e m ( s ) D e t e r m i n e R~sk and

protective Factors • •

C o n s i d e r Cultural

Factors

Review Relevant

Literature

Select/Implement Preventive Intervention

• • •

Universal

Selective Indicated

Desired Outcomes • •

Prevention Risk R e d u c t i o n

•

Sustained C o m m u n i t y Involvement Large-Scale Prevention Trials Ongoing Evaluation

• • •

Integration of P r e v e n t i o n Strategies into P r o f e s s i o n a l

Practice

Figure3. Collaborative interdisciplinary team model for substance abuse in communities.

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INTERDISCIPLINARY TEAM MODEL

with Faculty Fellows or found clinical preceptors among the Community Associates. As an example, a student worked with one Fellow on his intervention to provide home visits to drug-exposed neonates and their families. She then tested the effects of infant massage with this population as her thesis. Secondly, the team defined their populations, identified problems, and determined the risk and protective factors. Risks for the drug-exposed neonates were that mothers might return to substance abuse. Some protection was in place, however, as long as the mothers continued to attend the K.I.N.D.E.R. Clinic. Examination of cultural factors was also important during this second stage of the model. Considering the high percentage of bilingual students in predominantly Hispanic Carrillo Elementary School, it was important that all materials for students and parents be translated into Spanish. A Spanish-speaking Community Associate who was familiar with the neighborhood was critical to implementing "Say It Straight" training in that setting. Each team also became familiar with what, if any, preventive strategies were in place and then sought to augment those efforts with scientifically sound approaches. They consulted the growing body of prevention literature. At Carrillo, for example, basic drug education was in place through the D.A.R.E. (Drug Awareness Resistance Education) program, so the decision was made to add social resistance training. The third stage of the model consisted of the final selection and implementation of a preventive intervention. Universal interventions included providing "Say It Straight" training to two groups of young people, ie, elementary school students and college freshmen. The home visitation program for drug-exposed neonates and smoking cessation classes for college students were examples of selective interventions. Providing addiction education and developing a group adherence model for dually diagnosed patients is an indicated, preventive intervention according to the Mental Health Intervention Spectrum.

Outcomes

In the final stage, outcomes are examined. What has been the impact of prevention activities in these community settings? Have risks been reduced and protective factors enhanced? Dissemination of this information is underway. A number of presentations have addressed general outcomes of the interventions.

At this writing, final data analyses on the studies are in progress and Fellows and Community Associates anticipate publishing results elsewhere in the literature. One team has already published (Pollack, Steubben & Sobhan, 1997; Pollack, Steubben, Kouzeranani & Krajewski, 1998; Pollack & Stuebben, 1998; Pollack & Stuebben, in press). A second desired outcome, sustained community involvement, is evident in most settings. For example, there has been interest among civic groups in sustaining the home visitation program. Members of this team were invited to the mayor's office to discuss wider implementation of the intervention in the community. Funds are being sought to continue several of the projects. In the meantime, students continue this activity as part of their clinical practicum. The Group Adherence Model, including a workbook for clients, continues. The project with college athletes continues and has been expanded to include discussion groups. Large-scale prevention trials and ongoing evaluation are desired outcomes for the interventions. It seems likely that these, too, will occur for those programs that have been sustained in the communities. Several of the Fellows are designing new preventive intervention based on expertise acquired in this project. As an example, the gerontological nurse practitioner Fellow is now addressing the problems facing grandparents who are raising children of addicted parents. Prevention strategies are now taught in the curriculum and practiced by faculty and students, clear indicators that they will be integrated into professional practice. Specific applications of the model appear in Tables 1 through 3. In addition to the specific outcomes of the preventive interventions, a number of important outcomes resulted from the overall project. Faculty Fellows, Community Associates, and students have all gained expertise in substance abuse disorders. This has reTABLE 1. Home Visiting for Drug-Exposed Neonates Team

Faculty' Neonatal nurse practitioner Community associate pediatrician, students

Strategy Selective preventive intervent~on home wsttat~on

Target Populabon Drug-exposed neonates and families

Outcomes Increased maternal/family knowledge and skills in caring for infant Other study Effect of infant massage Sustained ~nvolvement ~ntwo sttes Student involvement Faculty expertise

MARIANNET MARCUS

166

TABLE2. Soctal Reststance Training for Fifth Graders in a Predominantly Hispanic School Team Faculty community health chntcal nurse spectahst and gerontological nurse Communtty associates b[hngual hcensed chemtcal dependency counselor Constable Prtnc~pal, social worker Teachers

Selected Strategy Untversal preventwe tntervent~on soctal resistance "Say It Straight" training

Target Population Fifth graders

Outcomes Increased ~esrstance awareness Ongoing tnvolvement tn school/community Another study planned

sulted in increased scholarship in the field through presentations and publications (Bailes, 1997; Kouzekanani & Neeley, 1997; Marcus, Rickman & Sobhan, 1999, 1998; Pollack, 1997; Pollack, Steubben, & Sobhan, 1997; Pollack & Stuebben, 1998; Pollack, Steubben, Kouzeranani & Krajewski, 1998; Pollack & Stuebben, 1998). Several Fellows are writing grants to sustain their preventive research beyond the pilot phase. Two Fellows have been named to federal prevention grant review panels. Fellows have also been asked to consult at other institutions. The number of prevention projects in the community has increased, and so has community awareness to the problems associated with substance abuse and need for prevention. The SON is seen as a major resource in designing preventive intervention. Community Associates are now prepared to sustain preventive interventions. The TABLE3. Group Adherence Model for Dually Diagnosed Clients Team Faculty psychtatnc/mental health chntcal nurse spectahst Community associate hoensed chemical dependency counselor

Strategy Indicated preventwe tnterventlon Determine factors that enhance adherence to group

Target Population Dually dfagnosed chents attendrng after-care groups

Outcomes Factors tdentrfied Chent workbook developed Ongoing studtes in progress Several pubhcat~onsand presentattons developed

number of lectures, continuing education offerings, workshops, and conferences devoted to substance abuse education and prevention has increased. These offerings have become increasingly multidisciplinary and team focused. Undergraduate and graduate curricula have been enhanced with prevention information, and the number of educational materials in this area has increased as Fellows have produced manuals, workbooks, and other publications. Linkages forged in the community continue and expand as Fellows move beyond the project period. Two new activities underway are a privately funded series of training workshops on substance abuse for area clergy and seminars and a CSAP-funded collaboration with the U T H H S C School of Public Health to develop faculty and increase educational offerings in that school. Conclusion

The major public health consequences associated with ATOD abuse continue to plague communities and frustrate the health care professionals who care for individuals and the communities in which they live. Research findings have shown that many treatment approaches are effective (Lamb et al., 1998). One challenge is educating community leaders and health care professionals to recognize and refer their constituents to treatment. A second major challenge is integrating effective prevention strategies into community-based care settings. This is a two-step process: (1) defining effective prevention, and (2) engaging community providers and other health care professionals in the process of providing that level of care. Effective prevention is not as well understood as is effecuve treatment. It is known that the original focus of prevention activities on the individual is not sufficient. Policy and environmental issues must also be addressed. Hence, it is important to build links between community groups and academic institutions to test theory-based interventions. Researchers then become sensitive to the needs and constraints of CBOs, and community providers learn the value of science in testing strategies for prevention. The model described earlier is one approach to accomplishing the necessary collaboration. The success of the model hinges on true collaboration. Community Associates participate as full partners by attending educational sessions, traveling to conferences as resources permit, and coauthoring presentations and papers. They are valued for their contribu-

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tions to the academic enterprise, the teaching of students. Faculty gain an in-depth understanding of the needs of the community. They have an opportunity to further their research trajectories, thus, advancing toward academic career goals. Students benefit from such collaborations and, ultimately, the health professions are better prepared to integrate prevention

segments of the Mental Health Intervention Spectrum into practice.

Acknowledgments The author acknowledges the contributions of Kamtar Kouzekanan,, PhD, evaluator, and Tanveer Sobhan, MD, MPH, research asststant

References

Bailes, B. (1997). Chronic alcohol abuse in elderly surgical patients. AORNJournal, 15, 963-971. Bates, M. E., & Labouvie, E. W. (1997). Adolescent risk factors and the prediction of persistent alcohol and drug use Into adulthood. Alcoholism: Clinical and Experzmental Research, 21, 944-950. Bellack, J. P. (1998). Changing roles, responsibilities, and employment patterns of registered nurses in ambulatory care settings. In E. O'Neil, & J. Coffman (Eds.). Strategws for the future of nursing (pp 113-143) San Francisco: Jossey-Bass Publishers. Blerman, K. L., & Greenberg, M. T. (1996). Social skills training in the fast track program. In R D. Peters, & R. J. McMahon (Eds.). Preventing childhood disorders, substance abuse, and delinquency. Thousand Oaks, CA: Sage Publications. Caetano, R. (1994). Drinking and alcohol-related problems among ethnic minority women. Alcohol Health and Research World, 18, 233-241. Caetano, R. (1995). The prevennon of alcohol-related problems among U.S. Hlspanics: A review. In P. Langton (Ed.), The challenge of participatory research: Preventing alcohol-relatedproblems in ethnic communities (DHHS Publication No [SMA] 95-3042). Washington, DC: Center for Substance Abuse Prevention Cultural Competence. Caetano, R. (1997). Prevalence, incidence and stability of drinking problems among Whites, Blacks, and Hispanics: 1984-1992. Journal of Studzes on Alcohol, 58, 565-572. Caetano, R., & Hines, A. M. (1996). Alcohol, sexual pracnces and risk of MDS among blacks, Hispanlcs and Whites. Journal of Acquired Immune Deflczency Syndromes, 10, 554-561. Campmha-Bacote, J. (1991). The process of cultural competence." A culturally competent model of care Wyoming, OH: Transcultural Care Associates. Carr, C. N., Kennedy, S. R., & Dimick, K. M. (1996). Alcohol use among high school athletes. The Prevention Researcher, 3, 1-3. Edwards, J., & Smith, E (1998). Impact of interdisciplinary education in underserved areas: Health professions collaboration in Tennessee. Journal of Professzonal Nursing, 14, 144-149. Ellis, A., & Harper, R. A. (1961). A guzde to ratmnal living. Englewood Cliffs, NJ: Prennce Hall, Inc. Englander-Golden, E, Golden, D. (1996). Say it Straight: Training m straightforward communication. Trainers Manual. Denton, Texas: Golden Communication Books.

Englander-Golden, P, Elconin, J., Miller, K., & Schwarzkopf, A. (1986). Brief Say It Straight training and follow up in adolescent substance abuse prevention. Journal of Primary Abuse Preventmn, 6, 219-230. Englander-Golden, P., Elconin, J., & Satir, V. (1991). Say It Straight: From Compulsion to Choices. Palo Alto, CA: Science and Behavior Books. Englander-Golden, E, Jackson, J., Crane, K., Schwarzkopf, A., & Lyle, P. (1989). Communication skills and self-esteem in prevention of destructive behaviors. Adolescence, 24, 481-503. Espmosa, L. M. (1998). School involvement and Hispanic parents. The Preventmn Researcher, 5, 5-6. Galin, E J. (1998). An empowerment prevention approach for Hispanic youth. The Prevention Researcher, 5, 10-12. Gay, G. (1998). Coming of age ethnically: Teaching young adolescents of color. The Preventmn Researcher, 5, 7-9. Gerstein, D. R., & Green, L. W. (Eds.) (1993). Preventmg drug abuse: What do we know? Washington, DC: National Academy Press. Gordon, R. (1983). An operational classification of disease prevention. Pubhc Health Reports, 98, 107-109. Hansen, W. B. (1992). School-based substance abuse prevention: A review of the state of the art in curriculum, 1980-1990. Health Education Research, 7, 403-430. Hansen, W. B., & Graham, J. W. (1991). Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus estabhshing conservative norms. Preventive Medicine, 20, 414-430. Hawkins, J. D., Catalano, R. E, & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. PsychologicalBulletin, 112, 64-105. Heyman, S. (1996). Psychological factors in athletes' substance use. The Preventmn Researcher, 3, 3-5. Kouzekanam, K., & Neeley, M. A. (1997). Coping styles of female cocaine addicts. Substance Abuse, 18, 165-171. Kumpfer, K. L., Molgaard, V., & Spoth, R. (1996). The strengthening families program for the prevention of delinquency and drug use. In R. D. Peters, & R. J. McMahon (Eds.). Preventing chddhood dzsorders, substance abuse, and delinquency (pp. 241-267). Thousand Oaks, CA: Sage Publications. Lamb, S., Greenlick, M. R., McCarty, D. (Eds.). (1998). Bridging the gap between practwe and research. Forging

168

partnerships with commumty-based drug and alcohol treatment. Washington, DC: National Academy Press. Marcus, M. T., Gerace, L. M., & Sullivan, E. J. (1996). Enhancing nursing competence with substance abusing clients. Journal of Nursmg Education. 35, 361-366. Marcus, M. T. (1997). Faculty development and curricular change: A process and outcomes model for substance abuse education. Journal of Professional Nursing, 13, 168177. Marcus, M. T., Rickman, K. A., & Sobhan, T. (1999). Substance abuse education liaisons: A collaborative continuing education program for nurses In acute care settings. Journal of Continumg Education m Nursing, 30, 229-234. Morgan, I. S., & Marsh, G. W. (1998). Historic and future health promotion contexts for nursing. Image, 30, 379-383. Mrazek, P..J., & Haggerty, R. J. (1994). Reducing msksfor mental di~orders:Frontiersfor preventive intervention research. Washington, DC: National Academy Press. National Center on Addiction and Substance Abuse. (1998). Behind bars: Substance abuse and America's prison population. New York: Columbia University. NIDA Notes (1998). Vol. 13, Number 4, U.S. Department of Health and Human Services, National Institutes of Health. O'Neil, E., & Coffman, J. (Eds.). (1998). Strategwsfor the future of nursing. San Francisco: Jossey-Bass Publishers. Pathways of Addiction: Opportunities in Drug Addictton Research (1996). Committee on Opportunities in Drug Abuse Research, Division of Neuroscience and Behavioral Health, Institute of Medicine. Washington, DC: National Academy Press.

MARIANNE T MARCUS

Poss, J. E. (1999). Providing culturally competent care: Is there a role for health promoters? Nursing Outlook, 47, 3O-36. Pollack, L. E. (1997). Demystifying the Betty Ford Clinic: An immersion experience. Journal of Psychosacml Nursing and Mental Health Services, 35, 14-19. Pollack, L. E., & Stuebben, G. (1998). Managing mental health and substance abuse problems after hospitalizatmn: What works and what doesn't. Workbook. Pollack, L. E., Stuebben, G., & Sobhan, T. (1997). Dually diagnosed inpatxent's satisfaction with addictions groups. Journal of Psychosocml Nursing and Mental Health Services, 35, 18-23. Pollack, L. E., Stuebben, G., Kouzekanani, K., & Krajewski, K. (1998). Aftercare compliance: Perceptions of people with dual dmgnoses. SubstanceAbuse, 19, 33-44. Pollack, L. E., & Stuebben, G. (1998). Addiction education groups for inpatients with dual diagnoses. Journal of the American PsychiatricNursesAssociation, 4, 121-127. Substance Abuse Among Older Adults. (1998). Washington, DC: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Tricker, R. (1996). Preventing substance use in young athletes. The Prevention Researcher, 3, 10-11. Vasquez, J. A. (1998). Distinctive traits of Hispamc students. The Prevention Researcher, 5, 1-4. Vasquez, E. (in press). Models ofcommumty nursing for the newborn. In L. Littleton, J. Engebretson, & L. Lotas (Eds.), Maternal child nursing. Wright, R. & Waits, T. D. (Eds.). (1985). Prevention of Black alcoholism" Issues and strategles. Springfield, Illinois: Charles C. Thomas Publisher.