DEVELOPING APPROPRIATE INTERVENTIONS FOR TARGET POPULATIONS

TABLE 1. Illustration of identifying target populations and interventions in drug abuse prevention research

IDENTIFICATION FACTOR

Unit of Personal/

Intervention _{Problem (P)} Trainer (S)Situation/

Environment (E)

Individual School

School dropout, Counselor, nurse Small group in child of alcoholics agency or school Mobility, Teacher, principal Class, staff desegregation/ meeting in school busing, teacher

turnover

Community Vandalism, drug- Law enforcement, Town hall, related crime judiciary, neighborhood

business, agency center leaders

DEVELOPING APPROPRIATE INTERVENTIONS FOR TARGET POPULATIONS

Once a target population is identified, a preventive intervention appro- priate to that population is developed. If there is strong evidence from previous research to support high external validity of a particular pre- vention program and the study or studies in which it was evaluated

provided a theoretical basis of the program that is either culture free or culture flexible, the program may be applied with little or no modifi- cation to the target population. Examples of these generalized applica- tions are life skills and social skills training that were developed originally as smoking prevention programs for white, middle-class populations and recently were applied effectively to inner-city black and Hispanic youth for prevention of drug abuse and Acquired Immu- nodeficiency Syndrome (Botvin et al. 1992; Schinke 1990). However, it is just as likely, if not more than likely, that an existing intervention shown to be effective as a primary prevention program with one population will require extensive modification for use with another target population. If there is no previous intervention research experi- ence with a specific target population and there is reason to believe that the target population is substantially different from other popu- lations, development of an entirely new intervention may be required, drawing on relevant etiologic and epidemiologic research to construct program content and delivery methods. If modification or new development is required, at least three factors should be considered: (1) conceptualization or placement of the intervention in a scheme of

strategic prevention that yields the strongest internal validity to the

study; (2) the unit of intervention that supports treatment construct validity; and (3) the probability of intervention effectiveness, an ecological validity concern.

Strategic Prevention

Some critics argue that current primary prevention programs for drug abuse are wasteful and off the mark because they are most likely to reach youth who will not use drugs (Klitzner et al. 1988; Moskowitz

1989; Newcomb and Bentler 1988). Federal agencies have issued several research announcements since the late 1980s that are aimed toward a delimited type of primary prevention that focuses on youth who exhibit high risk for future drug use based on person-level factors, such as family history of use or situation or environmental-level factors representative of underserved or disaffected groups. However, preven- tion that is aimed solely or predominantly at high-risk youth may pro- duce negative side effects. The most notable side effect is the possible negative social labeling by peers of youth who are singled out for special intervention (Burk and Sher 1990).

A more humane and internally valid alternative may be studies of prevention programs that represent one or more components of

strategic prevention in naturalistic settings where youth gather (Pentz

in press-b). Taken together, these components implemented in a large social unit such as the school or community would conceivably reach all youth, regardless of risk status. Conceptualizing strategic preven- tion as a package or scheme of program components enables the re- searcher to identify: (1) what types of youth are being served or underserved in an intervention setting; (2) which components are readily adopted and implemented and why; and (3) covariates for analysis of effects of individual program components delivered to the target population. Yet, to be evaluated systematically as a package in research, strategic prevention would include at least four components introduced sequentially during childhood or early adolescence and maintained through late adolescence. These components are:

1. Primary prevention programs with whole populations of youth in available, normative settings (e.g., schools, continuation schools, recreational service organizations, and clubs);

2. High-interest, special-topic activities and brief group counseling- oriented programs that are scheduled such that they complement the delivery of primary prevention programs, are elective or volun- tary, and address drug use questions that may be too complex or embarrassing to raise within the context of a primary prevention program (e.g., workshops or discussion groups on family alco- holism, depression, or suicide);

3. Standardized SAPS or outreach center counseling designed for

youth who have been identified by the school or justice system as being at high risk for drug use and other problem behaviors and which include—for evaluation purposes—standardized written and disseminated program content, procedures for program referral, and training of counselors or other program implementors; and

4. Prevention-treatment linkage consisting of standardized procedures for risk identification, treatment referral, and mainstreaming of youth back into school or job. Relatively little research exists on technologies for accessing, tracking, and subsequently intervening with hard-to-reach populations in unconventional settings (Pirie et

al. 1989). Studies that track and intervene with adolescents by linking health and drug abuse services with schools are one avenue for research in this area. Other possibilities are studies that reach out-of-school youth by utilizing settings and populations associated with treatment or law enforcement (e.g., drug prevention programs that are aimed at youth in families in which adults have been incarcerated for drug-related crimes).

Of these four components, primary prevention education has received the bulk of attention in ATOD prevention studies, but there have been relatively few fine-grained analyses of the differential effects of primary prevention with different target groups (Johnson et al. 1990). Alarmingly, special events/campaigns and assistance programs have been diffused and adopted throughout the United States with little or no evaluation in experimental studies and little specification of stan- dardized content and procedures by which to determine treatment construct validity. These components, particularly suited to hard-to- reach or hard-to-motivate target groups on the basis of face validity, call for vigorous pursuit in future ATOD prevention research. The fourth component, prevention-treatment linkage, can be further con- ceptualized as a systems intervention (see the discussion of unit of intervention that follows). Since no published ATOD prevention research exists in this area, extensive formative evaluation studies would be recommended before intervention trials are attempted.

Unit of Intervention

Developing an appropriate intervention for a target population requires consideration of three factors:

1. P, S, and E identification factors, particularly who has the major problem and what is the expected or preferred unit of behavior change;

2. Whether behavior change and hypothesized program mediators can be measured at that unit level; and

3. Resources available for and efficiency of delivering intervention at that unit level.

Consideration of these factors in selecting community as the unit of intervention is illustrated by the following complex example of a community (Pentz 1992a). The example is hypothetical. A commu- nity experiencing a rapid in-migration of several minority groups is subjected to several variables that serve as stressors on its capacity to organize and implement prevention programs effectively compared to other communities. These stressors include but are not limited to the following. An Anglo-Saxon-dominated government and culture in the United States tends to attribute a minority community’s problems to inferiority, genetics, or a failure to socialize; these attributions tend to depress community residents’ feelings of empowerment and categorize community leaders and agencies as passive recipients of government and social services. The pervasive myth that a minority community’s residents are automatically at high risk for health problems, drug abuse, and criminal behaviors has a self-fulfilling prophecy effect as well as decreasing perceptions of empowerment. Difficulty of acculturation to a majority social norm for behavior and secondary problems in acculturation conflict between adults who may prefer retention of another culture and youth who prefer rapid acculturation to majority norms weakens the capacity of the community and its res- idents to cope with other daily stressors, such as job and school. Attempting to accommodate to majority norms, the changing commu- nity may show an unusually high tolerance for conditions that would be considered unacceptable to other communities. Thus, by the time a critical incident or other initiating event occurs that establishes that community as a target for intervention, it may serve as a flashpoint for aggressive or destructive behavior before positive intervention can be realized. Finally, professionals, resources for prevention, formalized organizational structures to deliver prevention, and longevity of re- sources and structure may be unavailable or inaccessible to the com- munity. The net result in this community may be a slower, less vis- ible, less powerful community organizational process and support for prevention compared to other communities and a distrust of majority- dominated government and social services that renders achievement of ATOD policy change and dissemination and use of prevention

In this hypothetical example, the unit of change is arguably the com- munity, but the focus of intervention may be on changing systems- delivery services to include more indigenous minority program deliverers and infusing the community with additional prevention resources that are easily accessible to the in-migrating groups. The content of intervention may require a shared or sequential focus on creating job opportunities and making schools safe, as well as on ATOD intervention per se. Treatment construct validity then would be assessed according to whether the intervention includes systems-level change, whether it includes professional or paraprofessional training of community residents from the varied minority groups, and whether drug use change is mediated by change in economic, academic, or empowerment variables. An illustration of considering the unit of intervention in developing appropriate interventions for target popu- lations is included in table 1.

Probability of Intervention Effectiveness

At least four criteria or predictors of effectiveness should be consid- ered in developing appropriate prevention programs for a target popu- lation (Pentz 19923). All four are indicators of ecological validity of the intervention; they are:

1 . The extent to which prospective program implementors were aware of, or sought information about, a particular drug prevention pro- gram or approach that is later implemented (evaluated as an index of baseline technology transfer);

2 . The degree of program user-friendliness (evaluated by indices of quality of pilot program implementation and predicted target population program exposure);

3 . Consumer satisfaction (evaluated by early technology transfer to other units of intervention, variables representing dissemination and diffusion such as interpersonal communications in support of the program, and intentions to use or participate in the program,

4. Early changes in interim dependent variables during piloting (e.g., increased parent-child discussions about ATOD prevention or decreased positive expectations about drug use).

FORMATIVE EVALUATION AS AN AID TO IDENTIFYING