1. Measuring the Impact of Environmental Strategies in Prevention
Jeremy T. Goldbach, PhD, LMSW
C.A.R.E. Consulting Group
This product is supported by Florida Department of Children and Families Office of Substance Abuse and Mental Health funding.

2. Learning Objectives
After participation in this workshop, participants will be able to :
Explain the advantages of environmental strategies
Use data to identify environmental strategies that may be a good fit in their own communities
Measure the impact of environmental strategies in prevention

3. The next series of slides show risk and protective factors that surround a young person. Think of some protective and risk factors that could surround a young person like this boy.

4. This slide illustrates the protective factor of having supportive parents.

5. This slide illustrates the protective factor of extended family support.

6. This slide illustrates the risk factor of poverty.

7. This slide illustrates the protective aspect of friends.

8. This slide illustrates the risk factor of having an unsupportive teacher.

9. This slide illustrates the protective factor of having a supportive other adult or counselor.

10. This slide illustrates the risk factor: drug deals outside of school.

11. This slide illustrates heavy police presence, a risk factor.

12. This slide illustrates the risk factor of negative advertising.

13. This slide depicts the risk factor of having many liquor stores and bars.

14. This slide illustrates the risk factor of lacking parental supervision.

15. This slide illustrates the protective factor of having community supports.

16. This slide shows the original child as a reminder that the presence of protective and risk factors in his life will influence whether he will choose to use alcohol and other mood-altering substances.

17. What’s the point?!

18. So Why Environmental Strategies?
A significant portion of youth ages 12 to 17 in the United States have used alcohol and other drugs.
Rates of binge drinking (five or more drinks) in underage youth are a concern, with large increases between 7th grade (1.6% of 12 and 13 year olds) and high school graduation (34.7% of 18 to 20 year olds).
Economically, the costs of alcohol use and its related consequences in U.S. communities add up to more than $235 billion annually (Rehm, et al, 2009).
(NSDUH, 2009; Rehm et al. 2009)

19. Why environmental strategies Continued
Addressing alcohol abuse through only one strategy (such as a single direct service prevention intervention only) is less effective than taking a broader approach that includes the larger community.
multi-component strategies promote a systemic approach to solving issues recognizing that individuals operate within, and are affected by, an “environment”.
(Hawley, 1950; Rousseau & House, 1994; Stokols, 1996).

20. Breaking it Down
What are Environmental Strategies? Making flowers bloom? Ending Wars? Getting rid of pollution? NO…well, not for us anyway!

21. What Are Environmental Strategies?
Effect is on a population
What are environmental strategies
Prevention efforts aimed at changing or influencing:
Community conditions,
Norms and standards,
Institutions,
Structures,
Systems, and
Policies that contribute to substance use and consequences.
They focus on changing conditions in the physical, social and cultural environment of an entire community to create a setting that discourages substance abuse.
Speed bumps
No smoking ordinances
Note: The picture on the right is an environmental strategy that was implemented in Japan (and other places) when the women complained that they were being “gropped” on the crowded subways by men. “Women only” cars were designed as an environmental strategy to address this problem.
Environmental strategies do not have to be complex

22. Environmental Strategies
Environmental strategies focus on the following areas:
Access & availability
Policy/laws and their enforcement
Community norms/media messages

23. Access & Availability
Are the amount of time, energy, and money that must be expended to obtain a substance (alcohol, tobacco, drugs). The more resources it takes to get the substance (harder), the less the availability (access).
What are some examples of environmental strategies that impact availability?

24. Policies/Regulations/Laws
They control availability, support norms, and specify sanctions for violations.
What are some examples of environmental strategies that use policies / laws and enforcement?

25. Norms
The rightness or wrongness, the acceptability or unacceptability, and/or deviance of specific behaviors for a specific group of individuals.
What are some examples of environmental strategies that impact Norms?

26. Why Environmental Strategies?
Broad reach – universal population
Substantial effects
Immediate and enduring effects
Cost effectiveness
Ease of maintenance
What stands out for you in this list?
Environmental Strategies: seek to change the social context in which alcohol, tobacco, and drugs are used by reducing availability and spurring changes in normative beliefs about the acceptability of substance use. (Klitzner, 1999)
Environmental strategies involve longer-term, potentially permanent changes that have a broader reach (e.g., policies and laws that affect all members of society).
Effective prevention efforts will use both environmental and individual substance abuse prevention strate.gies

27. Share Your Experience
Discuss successes you’ve had in using environmental strategies
Discuss barriers/struggles in using environmental strategies

28. Selecting the Right Environmental Strategy
How do you know which type of environmental strategy is best for your state or community?
What do you need to know to decide which is best?
Can you do just one or should you do more than just one?

29. The SPF Framework Sustainability & Cultural Competence Assessment
Profile population needs, resources, and readiness to address needs and gaps
Monitor, evaluate, sustain, and improve or replace those that fail
Implement evidence-based prevention programs and activities
Develop a Comprehensive Strategic Plan
Mobilize and/or build capacity to address needs
Evaluation
Capacity
Implementation
Planning

30. Why Use the SPF? Effective capacity building process
Required by SAMHSA and used by many others
Gives a roadmap based on research, data, and evidence
Decisions can be evaluated through data-driven measurement

31. Step 1: Needs Assessments
Why do we assess?
To guide the prevention effort
To provide information about
the target population and their
corresponding substance abuse
problem

32. Key Elements Substance Abuse and Related Consequences
Risk and Protective Factors
Evidence- Based Prevention Strategies
Substance Abuse and Related Consequences
Environmental prevention requires a shift from “select an intervention” to a “prevention by design” approach focused on population-level change

33. Types of Risk/Protective Factors: “Why?”
Retail access
Social access
Pricing
Norms around Alcohol Issues
Enforcement
Promotion

34. Risk Factors for Binge Drinking
Substance Abuse
& Related
Consequences
Risk/Protective
Factor
Strategies
Binge Drinking
Social Access/
Availability
Retail Access

35. Risk Factor Assessment: “But Why Here?”
When does this happen?
Where does this happen?
How does this happen?
Who is affected?
Who allows this to happen?

36. But Why Here? Substance Abuse Risk/Protective & Related Strategies
Consequences
Risk/Protective
Factor
Strategies
Binge Drinking
Social Access/
Availability:
Parents in
community
host underage
drinking parties
Which is more of problem in your region?
Social access
Retail access

37. Step 2: Capacity Building
To find out what we already
have and what we need
Different types of capacity
(fiscal, physical, staff, etc)
- So we don’t duplicate efforts or pick much-needed, but unachievable strategies

38. Step 3: Planning What kind of planning is done?
Identifying the most powerful factors (intervening variables) contributing to the target behavior
Investigating appropriate evidence-based strategies to match population’s needs
Planning expected outcomes (both short and long-term)

39. Types of Environmental Strategies
Policy
Enforcement
Communication
Policy:
minimum age to buy
underage drinking laws
driving while intoxicated (DWI) laws
open container laws
limits on the location, density, and hours of operation of liquor stores
Enforcement:
Sobriety checkpoints
Compliance checks
Education:
Retail seller trainings
Retail server trainings
Curriculum targeting entire populations
Communication:
Social Marketing
Media Advocacy
Counter-marketing
Media Literacy
Social Norms Campaigns
Collaborations:
Businesses unite to prohibit underage drinking
Share resources and reduce duplication
Work with schools to keep substances off school grounds

40. Selection of Evidence-Based Strategies
Relevant?
Demonstrates “Conceptual Fit”
From Identifying and Selecting Evidence Based Interventions, US Department of Health and Human Services.
Conceptual (is it relevant)
Does it address the identified risk/protective factors (consistent with community’s logic model)?
Will it drive positive outcomes with the consequences you are trying to change?
Sufficient reach to move the needle in your community?
Practical (is it appropriate?)
Are the resources big enough to do this?
Is there support for this strategy?
Is there a readiness to act on this?
Will it reinforce other strategies (synergistic)
Does it address cultural needs of the community?
Evidence of Effectiveness (is it effective)
Is the strategy based on a well-defined theory or model
Is there demonstrated evidence of effectiveness for areas similar to those you will address?
Have the results been replicated successfully over time?
Appropriate?
Demonstrates “Practical Fit”
Effective?
Demonstrates “Evidence of Effectiveness”
Best Fit Prevention Intervention

41. Evidence-Based Environmental Strategies
Risk/Protective
Factor
Strategies
Substance Abuse
& Related
Consequences
Binge Drinking
Social Access
Enforcement
Social Host
Ordinances
RELEVANT
This slide illustrates examples of strategies that have a conceptual fit to the risk factor that we are targeting.
You see on the furthest left hand side the types of prevention strategies, including:
Policy
Enforcement
Communication
Education
Let’s look at these in terms of conceptual fit.
Do the strategies do the meet the following criteria:
Fits into community logic model (yes)
Drives positive outcomes in identified substance abuse problems (yes)
Addresses the community’s risk and protective factors and underlying conditions (yes)
Is based on evidence-based principles for target population (yes)
Targets multiple opportunities for intervention (yes)
By starting with the risk and protective factors and placing strategies within the logic model, we have insured that strategies will fit the logic model and will address the risk and protective factors.
How would you know if the strategies would drive positive outcomes?
Would they have been mentioned in the literature as evidenced-based strategies?
Does anybody have an example of a common strategy that many communities may use but does not result in positive outcomes?
Examples: mock car crash, having kids in recovery talk with general audience, a speaker talking to a large group of parents for one hour on a topic.
If you are in a coalition, and these types of non-conceptual fitting strategies are suggested, what do you do?
Communication
Social Marketing
“Parents Who
Host Lose the Most”

42. Key Elements for Success of Environmental Strategies
Use data for decision-making
Fit: relevant, appropriate and effective
Good mix of strategies
Monitor implementation and outcomes
Have adequate data identifying risk factor (intermediate variable)
• Clear and logical link from risk factor to environmental strategy selected
• Good mix of various types of strategies (policy, enforcement, media)
• Media will be less effective if done in isolation
• Plans should be relevant to various types of audiences and cultures
• Understand what levels of capacities are needed to implement
• Adaptations are carefully planned as well as documented
• Closely tied with evaluation efforts
• Monitor implementation and outcomes

43. Step 4: ImplementING What do we do?
Develop an action plan for implementing the strategic plan
Take fidelity of implementation into account
Write detailed evaluation plan that includes process and outcome measurements

44. Step 5: EvaluatING What do we evaluate?
The effectiveness of the selected evidence- based program, policy, or practice (EBP)
How?
By collecting required outcome data
Recommendations made for quality improvement

45. What is an Evaluation?
“The most serious mistakes are not being made as a result of the wrong answers… The truly dangerous thing is asking the wrong question.” – Peter Drucker
Asks questions to understand Who, What, When, Where, Why, and How things are being done
Identifies strengths and barriers to the coalition process
Identifies strengths in the implementation of your strategies
Identifies gaps and areas for improvement
Tells you about your PROCESS as well as your OUTCOMES

46. Evaluation is Important Because It… (I promise, there are real answers
“One of the great mistakes is to judge policies and programs by their intentions
rather than their results” – Milton Friedman
Helps to improve program planning
Monitors the effectiveness of strategies
Advances knowledge in the prevention sciences
Serves as a mechanism to build capacity by involving community in evaluation
Can encourage the community to publicize success stories from the prevention effort

47. Process Evaluation What is process evaluation? EXAMPLES:
What is it like to be a new member of the coalition?
To what extent is our strategy being implemented as planned?
What obstacles were encountered during implementation?

48. Outcome Evaluation
Over the duration of the program, to what extent has:
Coalition membership increased?
Community-wide prevention awareness activities changed adult norms about substance use?
Youth alcohol use decreased?

49. How Do We Explore These Questions Effectively?
Each activity that the coalition does should have a purpose
Each activity should be measureable and link logically to an outcome of interest

50. INTERVENING VARIABLES INTERMEDIATE OUTCOMES
The Logic Model
GOALS
INTERVENING VARIABLES
STRATEGIES
ACTIVITIES
SHORT-TERM OUTCOMES
INTERMEDIATE OUTCOMES
LONG-TERM OUTCOMES
30 DAY ALCOHOL USE IN 8TH GRADERS IS AT 20% AS MEASURED BY THE FLORIDA SCHOOL SURVEY
RETAIL ACCESS
RETAILER BEVERAGE SERVICE (RBS) TRAINING
IDENTIFY AREAS OF HIGHEST OFFENSE
COMPLETE RBS TRAINING OF TRAINERS
RECRUIT COMMUNITY PARTNERS
CONDUCT
RBS TRAINING WITH 50 RETAILERS PER MONTH
RETAILERS SELL LESS FREQUENTLY TO MINORS
COMPLIANCE CHECKS FIND FEWER NON-COMPLIANT RETAILERS
30-DAY ALCOHOL USE GOES DOWN IN 8TH GRADERS FROM 20% TO 15% FROM

51. What Lessons did we Learn?
“The only man who behaves sensibly is my tailor; he takes my measurements anew every time he sees me, while all the rest go on with their old measurements and expect me to fit them!”
- George Bernard Shaw

52. Sustainability and Cultural Competence
What are we sustaining, the prevention programs or the prevention effort?
Why is cultural competence important?
How do we create prevention systems with culturally responsive behaviors, attitudes, and practices?

53. Questions and Comments

54. Resources SAMHSA Center for Substance Abuse Prevention: www.samhsa.gov
centers/csap
National Institute on Drug Abuse:
C.A.R.E. Consulting, Online Training Resources: