(This resource corresponds to Module 1, Part 2.)

Many theories guide our prevention efforts. Highlighted below are a few of the ones most likely to inform the work you do.

Public Health Theory
Public health research uses data to study specific health problems, in particular, their frequency, their causes, and the kinds of people or groups affected. Armed with this kind of information, public health professionals design interventions targeted to specific groups of people. Over several decades, this has brought about a new understanding of cause and effect as well as a crucial word change: Events that were once considered acts of chance and were routinely called “accidents” are not, after all, chance events. They are predictable—and they are preventable. Prevention experts now speak of “injuries” or “car crashes” but avoid the word “accident.”

This understanding has spread to community agencies beyond public health. Many agencies strive to base their prevention strategies on evidence of the causes and patterns of substance abuse behaviors and on evidence of the strategies and programs that have been shown to make a difference.

The three-part public health model, shown in the CAPT framework, looks at the host, or individual person experiencing the health problem; the agent, the entity that causes harm; and the environment, the context in which the problem occurs and that influences the development of the problem.

Consider, for example, the case of alcohol abuse: The host is the individual who is drinking. The agent is the beverage—both its alcoholic content and the amount consumed (i.e., four martinis act as a more powerful agent than a single martini). The environment includes the liquor store outlets in a neighborhood, and advertising on television and in magazines that promotes beer drinking. (On the positive side, the environment also includes laws that prohibit driving while intoxicated, anti-drug media messages, laws that prohibit the sale of alcohol to minors, and community action that enforces age-21 drinking laws in bars or on college campuses, and DWI laws.)

As community agencies apply the public health model to specific problems, such as substance abuse, they need to understand this basic truth: Programs that use multiple strategies to achieve common goals and that affect all three contributing factors—host, agent, and environment—are more likely to succeed than programs that focus on only one kind of change.

Risk and Resiliency Theory
To design effective strategies for individuals, families, and communities, it is necessary to understand why some young people drink alcohol, smoke cigarettes, and use illicit and household substances (or fight or carry weapons) while others do not. Research finds that certain risk factors make it more likely that a particular young person will engage in substance abuse. Early and persistent antisocial behavior, a family history of substance abuse, and availability of alcohol, tobacco, and other drugs are examples of risk factors. Yet even children exposed to significant risk factors do not necessarily become involved with substances or encounter the problem behaviors associated with substance abuse once they reach adolescence. Protective factors in their lives—such as positive social orientation, an emotionally supportive family, and community norms unfavorable to substance use—can buffer these children from risk.

The risk and resiliency concept has contributed significantly to efforts in substance abuse prevention. The hypothesis behind risk and resiliency theory,¹ tested and supported by research findings, is as follows:

The more risk factors a child has, the more likely it is that he or she will become involved with substances and their related problems in adolescence and young adulthood.

• The more that these risk factors can be reduced, the less vulnerable to substance abuse the child will be.
  
  
• The more that protective factors can be increased, the more likely it is that the child will be buffered from risk.

In thinking about risk and resiliency, it is important to keep several points in mind. First, risk and protective factors are associated with substance abuse and other health problems; there is no one-to-one causal relationship between a particular factor and substance abuse. Second, reducing risk factors does not automatically increase protective factors; they are two different things. Effective prevention programs seek to do both: decrease risk factors and increase protective factors. Third, risk and protective factors can occur in all six aspects, or domains, of a child's life: individual, peer, family, school, community, and society.

Community Systems Theory
Community systems theory concentrates on the interactions among various sectors within a community—businesses and social service agencies, for instance—that affect the health and welfare of the community as a whole. The major intent is to challenge practitioners, who may place responsibility for substance abuse problems entirely on the individual, to think about a broader set of causes.

In recent years, practitioners have begun seeing more clearly that individual behavior takes place within a cultural, social, and environmental context. Various sectors within a community must work together and think carefully about the ability of each sector to react and adapt to conditions or changes in the economic, political, and social climate.

Once colleagues come together to think about local prevention in this larger, systemic way, they are better positioned to design a community prevention effort that attempts to build on preexisting social structures instead of creating new systems to solve the community’s substance abuse-related problems. With a focus on capacity building, practitioners are more likely to make positive changes that include the participation of many community stakeholders.² In their planning, they will take into account factors that affect substance use (by adults and youth), ranging from the available supply of substances to social norms that influence the acceptability of substance use to individual and group attributes that affect consumption.³ For example, a community that is interested in reducing the number of drunk-driving arrests and that adopts a multi-systems perspective might create a coalition of concerned citizens comprising liquor store and bar merchants, police officers, school officials, policymakers, parents, and young people.

Environmental Change Theory
Environmental change theory holds that by altering the larger environment that many people share—in their communities and their society as a whole—it is possible to bring about broad change that over time can dramatically affect the health and well-being of many people. Practitioners and program planners, as well as the family members in their programs, can take action steps to influence factors in the wider environment, specifically, community norms; ordinances, laws, and regulations; and the availability of tobacco, alcohol, and other drugs. For instance, one of the most effective types of environmental strategies is to create and enforce state and local laws that limit the availability of the “agents” (alcohol, tobacco, and other drugs) to the “hosts” (young people), as the following examples demonstrate:

• The age-21 drinking law has saved an estimated 15,000 lives since the mid-1980s, when all 50 states were required to raise the minimum drinking age.⁴
  
  
• Thirty-six states by legislation and 8 by case law have enacted “dram shop” laws, which hold servers responsible for serving to underage patrons.⁵ Some studies have shown a relationship between lawsuits against servers and a decline in car crashes.⁶ In states where lawsuits have created a high level of exposure to liability, alcohol establishments offer fewer low-priced drink promotions and more servers check identification.⁷
  
  
• Higher excise taxes on cigarettes appear to be among the most effective strategies for decreasing smoking by youth. One study estimated that doubling the federal excise tax on cigarettes in 1983 reduced the number of teenage smokers by 800,000.⁸

References

1. Hawkins, J. D., Catalano, R. F., and Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64–105.
   
   
2. Minkler, M. and Wallerstein, N. (1997). Improving health through community organization and community building. In K. Glanz, F. M. Lewis, and B. K. Rimer, (Eds.), Health behavior and health education (2nd ed.) San Francisco, CA: Jossey-Bass Publishers.
   
   
3. Holder, H. D. and Reynolds, R. I. (1998). Risk factors reflected in the community systems perspective for youth substance abuse. Presented as part of Prevention Planning for Youth Substance Abuse Initiatives at the 11th Annual National Prevention Network Research Conference, August 31, 1998, San Antonio, Texas; and Holder, H. D. (1998). Alcohol and the community: A systems approach to prevention. Cambridge, UK: Cambridge University Press.
   
   
4. DeJong, W. and Hingson, R. (1998). Approaches to the reduction of driving under the influence of alcohol. Annual Review of Public Health, 19, 359–78.
   
   
5. Digest of State Alcohol Highway Safety Related Legislation, 16th edition, 1988.
   
   
6. Wagenaar, A. and Holder, H. (1991). A change from public to private sales of wine. Journal of Studies on Alcohol, 52, 162–173.
   
   
7. Holder, H., et al. (1993). Alcohol beverage server liability and the reduction of alcohol-involved problems. Journal of Studies on Alcohol, 54, 23–36.
   
   
8. Lynch, B. S. and Bonnie, E. J. (Eds.) (1994). Growing up tobacco free: Preventing nicotine addiction in children and youth. Washington, DC: National Academy Press.