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Exploring the Strategic Prevention Framework (SPF) and Its Application to a Comprehensive Substance Abuse and HIV/ AIDS Prevention Initiative Evidence from Project C.O.P.E. (Communities Organizing for Prevention and Empowerment) ROBERT REID AND PAULINE GARCIA-REID

THE INTERNATIONAL JOURNAL OF INTERDISCIPLINARY SOCIAL AND COMMUNITY STUDIES thesocialsciences.com First published in 2013 in Champaign, Illinois, USA by Common Ground Publishing LLC www.commongroundpublishing.com ISSN: 2324-7576 © 2013 (individual papers), the author(s) © 2013 (selection and editorial matter) Common Ground All rights reserved. Apart from fair dealing for the purposes of study, research, criticism or review as permitted under the applicable copyright legislation, no part of this work may be reproduced by any process without written permission from the publisher. For permissions and other inquiries, please contact [email protected]. The International Journal of Interdisciplinary Social and Community Studies is peer-reviewed, supported by rigorous processes of criterion- referenced article ranking and qualitative commentary, ensuring that only intellectual work of the greatest substance and highest significance is published.

Exploring the Strategic Prevention Framework (SPF) and Its Application to a Comprehensive Substance Abuse and HIV/AIDS Prevention Initiative: Evidence from Project C.O.P.E.

(Communities Organizing for Prevention and Empowerment)1,2

Robert J. Reid, Montclair State University, USA

Pauline Garcia-Reid, Montclair State University, USA

Abstract: The inextricable link between substance abuse and HIV/AIDS poses a serious public health threat in the United States. Of particular concern has been the detrimental impact that this crisis has wrought on urban centers, where people of color, particularly racial and ethnic minority youth, are disproportionately impacted by this twin epidemic. The U.S. federal government has made a concerted effort to fund demonstration projects through its Minority AIDS Initiative (MAI) in geographic areas with high rates of substance abuse and HIV/AIDS prevalence, with the specific intent of introducing culturally-resonant, model prevention protocols with proven effectiveness. Responding to this public health emergency, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Prevention (CSAP), introduced the Strategic Prevention Framework (SPF) to guide prevention planning and implementation efforts throughout the U.S. This paper illustrates the five steps of the SPF (e.g., assessment, capacity, planning, implementation, and evaluation) by describing its application to Project C.O.P.E. (Communities Organizing for Prevention and Empowerment), which is a comprehensive substance abuse and HIV/AIDS prevention program located in the northeastern United States. Keywords: Substance Abuse and HIV/AIDS, Culturally-Tailored Model Prevention Protocols, Racial and Ethnic Urban

Minority Youth, Strategic Prevention Framework (SPF)

The Twin Epidemic – Substance Abuse and HIV/AIDS

he twin epidemics of substance abuse and HIV/AIDS pose a serious public health threat in the United States. A significant body of research has shown that risky behaviors associated with drug use continue to fuel the spread of HIV infection (National Institute

on Drug Abuse (NIDA) 2012). Of particular concern has been the impact that this crisis has wrought on urban minority communities, where African Americans and Hispanics now constitute 57% of all HIV/AIDS cases (Centers for Disease Control and Prevention (CDC) 2011a; CDC 2011b; NIDA 2012). Throughout these urban centers, racial and ethnic minority youth have suffered due to the health consequences of drug abuse and HIV. Approximately 39% of the new infections are occurring in young people between the ages of 13 to 29, and of those, 65% are among African Americans (CDC 2011a; CDC 2011c; NIDA 2012). A similar trend emerges for Hispanics in which the HIV infection rate in 2009 was nearly three times higher than among their non-minority counterparts (CDC 2011b). Based on these sobering statistics, it becomes

1 This paper was prepared with the support of the U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Prevention (CSAP), Grant No. SP-15104. The views expressed in this paper are those of the authors and do not necessarily represent the position of the sponsoring agency. 2 An earlier version of this paper was presented at the Seventh International Conference on Interdisciplinary Social Science, Barcelona, Spain, July 27, 2012.

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THE INTERNATIONAL JOURNAL OF INTERDISCIPLINARY SOCIAL AND COMMUNITY STUDIES

paramount to structure preventive interventions and health education messages that address the constellation of factors that disproportionately place minority adolescents at heightened risk for acquiring HIV infection – that is the intersection between substance abuse and sexual risk-taking behaviors.

Responding to this public health emergency, the federal government has made a concerted effort to fund demonstration projects through its Minority AIDS Initiative (MAI) in geographic areas with high rates of substance abuse and HIV/AIDS prevalence, with the specific intent of introducing prevention models with proven effectiveness (Substance Abuse and Mental Health Services Administration (SAMHSA) 2008). Project C.O.P.E. (Communities Organizing for Prevention and Empowerment) emerges as one such initiative that has received federal funding from the U.S. Department of Health and Human Services (HHS), SAMHSA , CSAP to develop and coordinate comprehensive substance abuse and HIV/AIDS prevention services for racially and ethnically diverse youth in a northeastern urban community. The target community identified for this project has among the highest rates in the state for both substance abuse and HIV/AIDS infection among African American and Hispanic/Latino residents. Prevention programs, however, are scarce. As a collaborative venture between a public university and numerous community-based organizations, this initiative has embraced the five stages of the Strategic Prevention Framework (SPF) – e.g., assessment, capacity building/mobilization, strategic planning, model program implementation, and evaluation (SAMHSA 2008) – with the purpose of empowering a community to take action in promoting positive youth development. This paper will illustrate the five steps of the SPF by describing its application to our project.

Strategic Prevention Framework (SPF)

Nearly a decade ago, SAMHSA introduced the newly formulated SPF to address the substance abuse prevention needs for state and local communities (Arthur, Hawkins, Brown, Briney, Oestrerle, and Abbott 2010, 246; Flewelling, Birckmayer, and Boothroyd 2009, 388; Piper, Stein-Seroussi, Flewelling, Orwin, and Buchanan 2012, 68). The SPF is grounded in a public health approach to prevention that examines a constellation of risk and protective factors across multiple systems such as individual/peer, family, school/work, and community (NIDA 2003, 6), which may either impede or promote population-level change (Community Anit-Drug Coalitions of America (CADCA) 2009a, 5). This public health model involves the integration of five major steps: 1) organize the community to profile needs and resources; 2) mobilize and/or build capacity to address needs; 3) develop a comprehensive strategic plan; 4) implement evidence- based prevention strategies and activities; and 5) monitor, evaluate, and sustain (Imm et al., 2007, 3; SAMHSA n.d.). By incorporating the common components of effective prevention programming through a risk and protective factor lens, the SPF has a wide range of applicability in preventing a host of public health concerns that may include the prevention of underage drinking and smoking, cancer, or diabetes (CADCA 2009a ; Flewelling et al. 2009, 388).

The SPF is driven on the concept of outcome-based prevention (SAMHSA n.d.). Funders have become increasingly concerned about the lack of quantifiable evidence in demonstrating program effectiveness. By adhering to a data-driven approach, community-level prevention programs are being held more accountable for producing measurable results pertaining to their defined goals and objectives (Reid 1999, 43). The SPF also allows for a more expansive approach to prevention, as compared to prior prevention initiatives that have often operated in silos by focusing on a singular social problem with limited and non-evidence based interventions (Flewelling 2009, 390). This was demonstrated in the latter part of the 1980s and the early 1990s when the response to HIV prevention focused on theory-based, cognitive behavioral models of behavior change (Beeker et al., 1998, 832). Since the introduction of the SPF, initiatives have begun to emerge that move beyond individual-level interventions and are now more

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comprehensive, coordinated, and far more capable of reaching a broader audience (SAMHSA n.d.).

Figure 1: SAMHA’s Five Steps of the Strategic Prevention Framework (Inn et al. 2007, 3; SAMHSA n.d.)

The Importance of Cultural Competence

SAMSHA has identified cultural competence as an integral component to the SPF. Cultural competence refers to the beliefs, knowledge, and skills necessary to work effectively with individuals different from one's self and further recognizes that issues of social justice are critical to the process (CADCA 2009c,11; Resnicow, Soler, Braitwaite, Ahluwala, and Butler 2000, 272). According to Imm and others (2007), “a commitment to cultural competence ensures that there is respect for the complexities of multiple cultures in communities” (3). Attending to the needs of diverse communities, the SPF requires that cultural competencies be infused and integrated across all five steps. Many prevention programs have begun to identify ways to increase ethnic/cultural awareness and pride, develop conflict resolution skills, and promote pro- social competencies that focus predominantly on the external characteristics (i.e., surface structure of culture). These prevention initiatives tend to rely on people, language, food, and music that are known to and preferred by the intended population to increase the receptivity, comprehension, and acceptance of messages (273). Yet, the deeper structure level of culture is also needed to determine how social, psychological, and environmental factors can shape behavior within and across ethnic groups. It is recommended that strategies targeting substance abuse and HIV/AIDS prevention among racial and ethnic minority youth embrace various dimensions of cultural sensitivity that will not only increase the receptivity of the interventions (i.e., surface structure activities), but will also combine culture, history, social forces, and core values as an avenue to stimulate change (i.e., deep structure) (273). Programs should consider tailoring their prevention messages to attend to the specific strengths and needs of their respective communities (Reid, Garcia-Reid, Klein, and McDougall 2008, 419). For instance,

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understanding the importance of immediate and extended family ties in the Hispanic community (known as familismo) can help shape preventive interventions that resonate with its intended audience.

The Importance of Sustainability

Sustainability refers to the “ability of a program to maintain the human, social and material resources needed to achieve long-term goals for community change” (CADCA 2009e, 10). As a “cross cutting” element of the SPF, it should also be considered throughout the assessment, capacity, planning, implementation, and evaluation phases. Sustainability activities need to be introduced during the early stages of an initiative being mindful of long-term goals for community change. However, achieving these goals will not only require maintaining existing resources (e.g., human, social, and material), but also identifying and leveraging additional opportunities for growth and development (10). For example, a sustainability working group may be formed at the onset of the project with the purpose of exploring and identifying various funding streams at the federal, state, and local levels, as well as private foundations. The success of sustaining a viable prevention program depends on a multitude of factors, such as creating a stable infrastructure, providing quality training systems, and securing community support. Additional elements to consider throughout this process include building ownership among stakeholders, disseminating program successes, investing in capacity, and developing the systems necessary to support these activities over time (SAMHSA n.d.).

Step 1: Assessment

Because the nature and extent of drug abuse and the HIV/AIDS epidemic vary widely, prevention strategies must be adapted to local community needs and resources. Local drug use and HIV/AIDS risk-behavior patterns must be tracked to refine program approaches over time and to evaluate program outcomes. Conducting a community-wide needs assessment to identify the magnitude of particular social problem emerges as the first step in the SPF (CADCA 2009a, 10; Imm et al. 2007, 13). This process includes an assessment of the risk and protective factors associated with the problem. To address the intractable nature of substance abuse and the spread of HIV infection among urban minority youth, a coordinated and sustained prevention initiative that adheres to the SPF will focus on identifying common risk factors while promoting protective factors (SAMHSA n.d.). According to a cost-effectiveness study of school-based drug prevention programs conducted by Caulkins and colleagues (1999, xxxii), the implementation of nationwide model prevention programs seems to be justifiable in that the resulting benefits would likely outweigh the costs of the resources used to implement such interventions. In addition, it provides an opportunity to identify community assets and resources, while simultaneously exploring gaps in services and capacity.

In developing a comprehensive needs assessment to profile population needs, we utilized a multi-level approach that included a variety of data collection methods and resources. During both our first and second waves of funding (e.g., 2003-08 and 2008-13), the systematic gathering and analysis of data regarding our target population involved the following: 1) conducting focus groups and semi-structured qualitative interviews with at-risk African American and Hispanic/Latino adolescents; and 2) administering a school-wide youth survey to assess the degree of substance abuse involvement and the level of HIV-risk-taking behaviors among a random sample of urban minority youth. This survey contained CSAP-Core Measures (SAMHSA 2008) and sexual behavior questions from the CDC Youth Risk Behavior Survey (CDC 2012). The interview guides and questionnaires identified for these data-collection processes were developed using a risk and protective factor framework (i.e., examining issues

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across the following life domains: individual/peer, family, school, and community) and included outcome measures pertaining to sexual health and drug use.

Focus group interviews revealed significant concerns among youth in the identified service area. For example, adolescents who participated in the interview process poignantly described an insidious presence of drugs, crime, and violence that is ravaging their community. These findings were further substantiated by a comprehensive, school-wide, needs assessment survey that was administered to 991 high school students in our target community (see Table 1.). Risk factors contributing to the needs of our study population are highlighted below:

Table 1. Needs Assessment Findings Individual Risk Factors Sexual Risk

 More than 50% of respondents reported having sexual intercourse.  More than 35% of the students had sexual intercourse for the first time before the

age of 16.  More than 20% of the survey participants have had more than 4 sexual partners.  More than 12% of the students stated that they were physically forced to have

sexual intercourse against their will. Alcohol and Drug Use

 More than 50% of students reported using alcohol, with more than 20% claiming that they were younger than 13 years of age when they had their first alcoholic beverage.

 Approximately one third of the respondents felt that it would be very easy to obtain alcohol.

 About one third of the students drank alcohol within the past 30 days, and more than 20% admitted to drinking 5 or more drinks in a row within a couple of hours.

 More than 20% of the students reported marijuana use.  More than 20% claim that it would be very easy for them to obtain drugs like

cocaine, LSD, or methamphetamines. Other Individual Risks

 More than 40% of the respondents reported feeling unhappy, sad, or depressed within the 6 months prior to the survey.

Peer Risk Factors  More than half of the respondents have friends who are gang members.

Family Risk Factors  More than a quarter of the students reported that there is a lack of communication

among their family members.  More than 20% of the students reported verbal conflict in their families.

School Risk Factors  Nearly 50% of the students reported lack of support from their school staff.  Approximately 35% of the respondents acknowledge a gang presence in their

schools. Community Risk Factors

 More than 65% of the respondents acknowledged drug selling and crime in their neighborhoods.

In our effort to assess the target community’s readiness for change, we also embarked upon

the following activities: 1) focus-group interviews with key community stakeholders (e.g., local politicians, clergy, law enforcement, school officials, and business leaders) to determine what

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factors place youth at risk for substance abuse and HIV infection, and explore the ways in which adolescents are protected from engaging in risk-taking behaviors; 2) a community-network analysis to identify community assets and resources, as well as gaps in services and capacity; and 3) a random digit dialing (RDD) survey to evaluate the impact of substance abuse and escalating HIV infection rates among a randomly selected sample of community residents. These collective needs assessment activities helped our initiative meet a variety of objectives – e.g., enabled consensus about the scope and detrimental impact of substance use and HIV/AIDS problems in the community; provided collateral support in identifying the underlying factors that contribute to those problems; aided in the identification and analysis of environmental, social, and individual factors associated with the primary areas of concern; and guided the selection of policies and programs aimed at reducing substance use and HIV/AIDS problems in the community and establishing a baseline to track progress (CADCA 2009a, 11; SAMHSA n.d.).

Step 2: Capacity

Once communities have completed their needs assessment activities and have identified their prevention priorities, they can begin to enhance capacity and harness local resources as a means to implement effective programs, practices, and strategies. Success during this “capacity- building” phase of the SPF framework will require that programs and practices are accepted and well-supported by the community. Building trust among community stakeholders is not an easy undertaking as it requires time to cultivate relationships and partnerships. Program developers are encouraged to engage community members in the development, implementation, and evaluation phases of the proposed intervention. In addition to adopting this collaborative approach, it is important to introduce prevention protocols that show sustainable, outcome-driven results. These combined efforts could increase the likelihood of obtaining demonstrable program outcomes.

Research has demonstrated the importance of community support and involvement at the local level to help initiate such policy changes and to sustain durable shifts in the social environment (CADCA 2009b, 9; NIDA 2003, 13; SAMHSA n.d.). SAMHSA’s Collaborative for the Application of Prevention Technologies has identified four key components of the capacity-building phase and is illustrated with specific examples from our initiative (SAMHSA n.d.):

Improving Awareness of Substance Abuse and HIV/AIDS Problems and Readiness of Stakeholders to Address These Problems

During the initial stages of our funding cycle, several focus group interviews were conducted with key stakeholders in the community to explore the service needs of its adolescent population. One of the more salient themes that emerged from the findings was that the social problems plaguing youth were exacerbated by unmet treatment needs and gaps in social-service delivery among the city’s community-based organizations. Group members represented all segments of the community, such as municipal government, law enforcement, health and human services, faith-based institutions, community-based organizations, parents, youths, and the public school district. Participants indicated that the service delivery system for at-risk youth was hampered by the following factors: 1) lack of integration and coordination among service providers; 2) evidence of a gang problem plaguing youth in the identified community; and 3) lack of resources for adolescents who are at risk for substance abuse and HIV infection. For example, throughout the entire community that is comprised of approximately 30,000 youth under the age of 18, there was only one substance abuse prevention program and two HIV prevention programs serving the entire city. The focus groups further revealed a strong commitment among community members

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and stakeholders in attending to the myriad of public health problems adversely impacting the city’s racial and ethnic minority youth.

Strengthening Existing Partnerships and/or Identifying New Opportunities for Collaboration

Engaging and involving a range of partners committed to a similar vision is an essential aspect of community mobilizing. By developing an expansive network of community providers, there are increased opportunities to share resources and information, and to reach greater numbers of at- risk youth with a host of strategies, in a variety of settings (SAMHSA n.d.). For example, during the early stages of this process, we cultivated numerous relationships with key stakeholders throughout the community, which included Memoranda of Understanding with more than thirty community-based organizations such as clergy, law enforcement, municipal government, and the local school district. Building a prevention team that represents the various sectors of the population and have a range of expertise in or represent the target population will improve outcomes leading to sustained results.

Improving Organizational Resources

At the local level, this often refers to the establishment of planning groups that reflect the demographics of the community, with a particular emphasis on improving workflow efficiency and effectiveness (e.g., identifying members, delegation of responsibilities, and decision-making) (SAMHSA n.d.). Community-level planning groups that are on the frontlines may further expand their reach by eliciting the support of other state-level systems such as juvenile justice and public safety. These entities can provide skills, training, and technical assistance regarding the implementation of policy initiatives that will augment the planning and development of coordinated prevention activities. Regarding our present work in the community, we have served on various coalitions, task forces, and substance abuse and HIV/AIDS planning workgroups at both the municipal and state levels, all with the shared purpose of improving the quality of life for at-risk youth.

Developing and Preparing the Prevention Workforce

The effectiveness of any prevention initiative depends on the training, knowledge, and experience of the staff delivering the intervention. Through a solid workforce development plan, programs are encouraged to provide ample opportunities for practitioners to become well-versed in a variety of intervention approaches that will enable them to effectively intervene on behalf of their service population (SAMHSA n.d.). For instance, our prevention team is predominately comprised of a blend of undergraduate majors from the fields of family and child studies, public health, psychology, and sociology and graduate level social workers, counselors, and public health educators with extensive experience working with high-risk populations. Prevention intervention specialists are provided with ongoing intensive trainings facilitated by the program coordinator and enhanced by experts in their respective fields of practice on topics ranging from sexual health, gangs, youth violence conflict negotiation, decision-making, cultural competence, and diversity. To further develop their understanding of the community, prevention team members volunteer at community-based organizations throughout the service area prior to initiating the health education workshops. Additionally, as a means of strengthening our community ties and increasing receptivity, we introduced culturally-tailored prevention intervention approaches that were shown to be effective in preventing and reducing the onset of substance abuse and HIV transmission among at-risk minority subpopulations. Finally, to create awareness and to mobilize the community toward action, our prevention team provided

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workshops and training for community stakeholders, service providers, and families on strategies to address a variety of social problems impacting at-risk adolescents in the target community. These collective activities enabled our team to galvanize the community around these pressing issues, thereby leading to the development of a strategic plan to help guide our work in the community.

Step 3: Planning

A comprehensive strategic plan is an integral component of the SPF framework as it not only provides a vision for prevention programming, but more important, it articulates a clear direction for organizing and implementing prevention activities. According to SAMHSA (2008), “the strategic plan must be based on documented needs, build on identified resources/strengths, set measurable objectives and include the performance measures and baseline data against which progress will be monitored ” (8). It is also important to note that this is not a static process, and as a prevention program evolves, its plan must be continuously assessed and adjusted in response to ongoing needs assessment and monitoring activities (Flewelling et al. 2009, 389). Further, intensive efforts should be undertaken at the inception of the planning process to integrate sustainability activities that will contribute to the permanent expansion of coordinated prevention programs throughout the community.

The strategic planning process requires that a diverse group of stakeholders create a plan with goals, objectives, and action steps aimed at addressing the social problems impacting their community. Table 2. illustrates the goals and measurable objectives that emanated from our project’s strategic planning process:

Table 2. Strategic Planning – Project Goals and Objectives Project Goals Objectives

1. Decrease the incidence of substance abuse and HIV infection among African American and Hispanic/Latino youth in an urban community located in the northeasternUnited States

1a) Program participants will report a reduction in neighborhood, family, peer group, and individual risk factors. 1b) Program participants will report an increase in attachment to community and family, increased pro-social norms, improved school performance, and greater involvement with pro-social activities and peers.

2. Increase the capacity for integrated prevention activities in the community.

2a) Increase social network and support systems that can promote and sustain social cohesion in the community; 2b) Increase opportunities for youth to function as active and contributing members of the community and participate in cooperative learning and shared decision making; and 2c) Establish cultural norms that set high standards of behavior for young people, including clear norms regarding drug use and sexual behavior, and that value youth as community members. *It is important to note that changing “cultural norms” is considered a distal outcome, which will require time, resources, and community

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investment to realize. 3. Increase service utilization and participation in substance abuse and HIV prevention activities by at-risk youth, which will include referrals to HIV counseling and testing sites.

3a) Engage children in educational enrichment and skill-building activities; build morale and foster attachment to the goals of the program; and 3b) Maximize the number of youth who complete the program and are referred to pre and posttest HIV counseling and testing sites.

4. Increase cultural identity and pride among at-risk youth.

4a) Provide programs and messages that use culture, ethnicity, history, and core values as a medium to motivate behavior change; and 4b) Ensure that staff are sensitive to the cultural needs of the target population.

Once the goals and objectives have been identified, the planning group adopts a logic model, or framework for action, which essentially serves as a graphical representation of the project. As an illustrative planning tool, the logic model links inputs (resources) and program components (activities) that have been identified to bring about the desired outputs (objectives) and outcomes (goals) (CADCA 2009d, 13;,SAMHSA 2008, 42). Logic models further serve to inform the fifth and final phase of the SPF framework – i.e., evaluation – by allowing prevention programs to critically analyze the progress that they are making toward their goals.

Figure 2. provides a sample logic model that was developed for the purpose of our project.

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Figure 2: Logic Model

Step 4: Implementation

U.S. federal initiatives, sponsored by both CSAP and the CDC, , have been launched to promote widespread dissemination of science-based prevention strategies in disproportionately at-risk minority communities. The evidence-based programs identified through these U.S. federal registries and listings are based on research that indicates a comprehensive approach to prevention should reduce risk factors (i.e., sexual risk-taking behaviors) while enhancing protective factors (i.e., personal negotiation and resistance skills). According to Arthur et al. (2010), “these initiatives are intended to disseminate prevention research, encourage data-driven planning, and mobilize community stakeholders to utilize tested, effective strategies to prevent adolescent drug use and related problems” (246).

To meet this objective, in 2003, SAMHSA initiated the National Registry of Evidence-based Programs and Practices (NREPP) project as a systematic way to identify, promote, and implement science-based prevention strategies (SAMHSA 2012; Sherman 2010, 2; Springer and Philips 2007, 2). Model program status requires that protocols are carefully implemented, thoroughly evaluated, and produce consistent, positive, and replicable results that are readily disseminated to the broader prevention community. In addition to NREPP, the CDChas

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developed a compendium of HIV risk reduction (RR) evidence-based behavioral interventions (EBIs) that are classified as either best-evidence or good-evidence (CDC n.d.b). These interventions represent the strongest HIV behavioral interventions in the scientific literature to date that have been rigorously evaluated and have demonstrated evidence of efficacy. The compendium includes individual, group, and community-level behavioral interventions for high- risk populations that focus on sex or drug-related risk behaviors and have proven to either reduce HIV or STD incidence or HIV-related risk behaviors, or increase HIV risk-reduction behaviors (CDC n.d.b). Key to successfully addressing the concomitant problems of substance abuse and HIV/AIDS will be the integration of evidence-based programs at the local level. For example, community-based organizations are on the front lines of mitigating the multitude of health disparities experienced by vulnerable members of the population and are well positioned to address their service needs.

According to the prevention principles proposed by NIDA (2003) , “Community prevention programs that combine two or more effective programs can be more effective than a single program alone” (13). Building upon these guiding principles, we have adopted an eclectic substance abuse and HIV prevention approach that includes community mobilizing, intensive case management, and interactive education-based interventions. The intensive case management model (i.e., CASASTART) and HIV/AIDS prevention curricula (e.g., Be Proud! Be Responsible, Focus on Youth, and Street Smart) have been rigorously field-tested and evaluated by CSAP and the CDC.. Based on prior research, this multi-tiered strategy has proven to be an effective method for reducing substance abuse and HIV risk among African American and Hispanic/Latino adolescents (13). The following section provides a description of the model programs included in our initiative:

Model Programs

CASASTART

This CSAP-endorsed prevention protocol (Striving Together to Achieve Rewarding Tomorrows) has been identified by SAMHSA as a model substance abuse prevention program. CASASTART was originally developed as a substance abuse and violence prevention program serving high-risk adolescents and their families living in socially distressed neighborhoods (Murray 1999, 8; Murray and Belenko 2005, 919). The program is a comprehensive, neighborhood-based, school- centered model that aims to provide coordination among police, schools, and community-based organizations to achieve two goals: 1) to redirect and build resiliency in the lives of youth who are at risk of using drugs, becoming delinquent, or dropping out of school; and 2) to reduce and control illegal drug use and related crime in the neighborhoods where the adolescents live to make the areas safer and more nurturing environments (9). CASASTART has served as our program’s organizing framework and we have incorporated core elements of this model (e.g., community mobilizing and intensive case management) into our comprehensive prevention plan as a means of addressing the unique demands of at-risk youth in our service area.

To further contextualize our prevention plan, we have identified three CDC-endorsed HIV prevention curricula (e.g., Be Proud! Be Responsible!, Focus on Youth, and Street Smart) that are culturally responsive and attend to the service needs of our target population (CDC n.d.a,c,d). Salient aspects from each of these behavioral interventions (e.g., small group discussions, interactive group activities, video presentations, and condom demonstrations) have been integrated into our prevention intervention service plan.

Be Proud! Be Responsible!

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Be Proud! Be Responsible! encourages participants to build a sense of pride and self-worth, develop a futuristic orientation, and behave in a responsible manner. The curriculum consists of six, 50-minute modules and employs educational videos, films, role-plays, games, exercises, and condom demonstrations to increase knowledge of HIV transmission and prevention, risk reduction, condom use, safe-sex behaviors, confidence, personal negotiation and resistance skills (CDC n.d.a).

Focus on Youth (FOY)

Focus on Youth (FOY) is an eight-session intervention that utilizes discussions, games, and multimedia formats to actively engage youth in HIV/AIDS education/prevention activities. The program is comprised of seven, 90-minute sessions that focuses on decision-making, negotiation skills, communication, values clarification and goal setting, as well as educational information pertaining to condom use. Health education topics also include facts regarding AIDS, STIs, contraception, and human development. The curriculum is further enhanced by booster sessions in which program participants are given specific challenges to work through to reinforce the skills (e.g., decision making, communication, and condom use) that were developed throughout the primary phase of the protocol (CDC n.d.c ).

Street Smart

Street Smart is a multisession, skills-building program that was originally developed to help groups of runaway youth reduce unprotected sex, number of sex partners, and substance use. Delivered in a small, group session format, the intervention consists of eight, 1.5 to 2 hour sessions delivered over a two to six week period. During the initial stage of the intervention, HIV/AIDS prevention information is shared through multi-media approaches, such as video and art workgroups. This provides a comfortable and safe forum in which youth review and discuss commercial HIV/AIDS prevention videos and then develop their dramatizations, public service announcements, commercials, and rap songs. The primary focus of these sessions is a social skills building approach, with a particular emphasis on assertiveness and coping. Exercises are then introduced to help adolescents identify their emotional and behavioral reactions and unrealistic expectations in potentially high-risk situations (CDC n.d.d).

Step 5: Assess Performance

Ongoing monitoring and performance assessment activities are integral components to ensuring a program’s success. Through a carefully orchestrated evaluation plan, programs are able to gauge their effectiveness, ensure the quality of the proposed interventions (i.e., fidelity), identify best practices, and encourage continuous quality improvement (SAMHSA 2008, 13). A variety of evaluation designs and data collection methods may be utilized to conduct the process and outcome evaluations. The process, or formative, evaluation phase of the project may include focus group and semi-structured interviews with program staff and key informants (e.g., referral sources, advisory board members, and program participants), participant observation, and archival program records such as staffing patterns, attendance sheets, meeting minutes, and other records required of the initiative (CADCA 2008, 16). The purpose of the formative evaluation is to assess the degree to which the services provided accurately replicate the selected prevention models and preserve its fidelity. For example, we recently conducted qualitative interviews with at-risk youth who have not participated in our program as a means of understanding environmental influences that may impede their receptiveness to HIV/AIDS prevention messages in their community. A recurring theme that emerged among the adolescents was the lack of support that they received from adults in their neighborhoods, including parents and teachers.

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In addition to collecting and analyzing process information, it is important to identify the program/contextual factors (i.e., dosage data), and consider individual/peer, family, school, and community-level variables, which may be associated with the desired program outcomes (i.e., a reduction in substance abuse and HIV/AIDS risk taking behaviors). An outcome evaluation provides data to help ascertain whether the prevention strategies delineated in the strategic plan meet the intended goals and objectives of the initiative (CADCA 2008, 18). There are many issues to consider when embarking upon an outcome evaluation – e.g., survey development, data collection, evaluation design, data analysis, and reporting – that require careful planning and implementation (18). For our purposes, we used performance measures identified by SAMHSA that defined key priority areas related to substance abuse and HIV/AIDS knowledge, perceptions, and behaviors (SAMHSA 2008, 12). By incorporating a quasi-experimental pretest-posttest nonequivalent comparison group design, we were able to show that our interventions were on track to achieving many of its critical programmatic objectives. For instance, preliminary analyses have revealed that program participants with higher levels of program involvement (i.e., dosage) tended to report lower levels of tobacco use, alcohol, and illicit drug use.

However, there are inherent limitations when embarking upon this type of outcome-based evaluation research with an adolescent population. More specifically, obtaining parental consent among targeted youth has been at times challenging due to a lack of cooperation in returning the necessary forms and paperwork. While addressing this issue has not been an insurmountable obstacle to overcome, it has required a significant re-allocation of resources, manpower, and time. Consistent with the SPF guidelines, we have begun to disseminate our evaluation findings with the broader prevention community to share both lessons learned and program successes. Concluding Comments The strategic prevention framework (SPF) served as an invaluable tool in guiding our prevention work in a disenfranchised, urban community. From the initial steps of the process, we identified a paucity of prevention programs serving a large city that has been inundated by a multitude of public health concerns. Unfortunately, a lack of resources, poor coordination among service providers, and major gaps in service delivery have compounded the myriad of social problems experienced by adolescents residing in this high-risk community. As a collaborative effort between a public university and numerous social service agencies, our project has helped transform the way the community is served by increasing the capacity of local, community-based organizations. With the support of our partners, our prevention team has developed a comprehensive strategic plan that has led to the coordination and implementation of culturally appropriate, evidence-based substance abuse and HIV/AIDS prevention protocols with proven effectiveness throughout the target community. Through a rigorous evaluation process, we were able to demonstrate that youth participating in our program exhibited significant reductions in alcohol and drug use behaviors and marked increases in social support, family cohesion, and community involvement. We will continue to work toward sustaining and expanding the scope of services in our ongoing effort to mitigate the adverse health consequences associated with illicit drug use and risky sexual behaviors among vulnerable and at-risk urban minority adolescents.

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Caulkins, Jonathan P, C Peter Rydell, Susan S Everingham, James Chiesa, Shawn Bushway. An ounce of prevention - a pound of uncertainty: The cost-effectiveness of school- based prevention programs. Santa Monica, CA: Drug Policy Research Center - RAND Corporation, 1999.

Community Anit-Drug Coalitions of America (CADCA) - National Community Anti-Drug Coalition Institute. Assessment primer: Analyzing the community, identifying problems and setting goals. Alexandria, VA: National Community Anti-Drug Coalition Institute, 2009a.

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Outcomes with the SAMHSA Strategic Prevention Framework to Achieve Results. Santa Monica, CA. RAND Corporation, 2007.

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ABOUT THE AUTHORS

Dr. Robert Reid: Robert J. Reid, PhD, is an Associate Professor in the Department of Family and Child Studies, College of Education and Human Services, at Montclair State University. His research has focused on the development, coordination, and testing of community-wide prevention initiatives to reduce risk factors and to promote protective factors associated with various health behaviors, such as adolescent substance abuse, sexual risk, and youth violence. Dr. Reid’s research has continually examined the factors that may either enhance or constrain the quality of life for children, families, and communities. Since 2003, he has served as Principal Investigator on a Minority AIDS Initiative (MAI) grant, which is funded by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Prevention (CSAP). Through this decade-long initiative, Dr. Reid has developed and coordinated comprehensive substance abuse and HIV/AIDS prevention services targeting underserved racial and ethnic minority youth in the city

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of Paterson, New Jersey. More recently, Dr. Reid has been funded by the White House Office of National Drug Control Policy and SAMHSA to continue his prevention work in the Paterson community by developing the infrastructure of an anti-drug coalition targeting at-risk urban minority adolescents.

Dr. Pauline Garcia-Reid: Pauline Garcia-Reid, PhD, is an Associate Professor in the Department of Family and Child Studies, College of Education and Human Services, with an affiliate appointment in the Center for Child Advocacy and Policy, College Humanities and Social Sciences, at Montclair State University. Her research interests include youth substance use and violence prevention, social justice and advocacy within a culturally-grounded social work lens, and practice and research with racial and ethnic minority children and families. She has also served as a technical advisor to the SAMHSA National Registry of Effective Prevention Programs Project (NREPP).

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The International Journal of Interdisciplinary Social and Community Studies is one of eight thematically focused journals in the collection of journals that support the Interdisciplinary Social Sciences knowledge community—its journals, book series, conference and online community.

The journal presents studies of the social that exemplify the disciplinary and interdisciplinary practices of the social sciences.

As well as papers of a traditional scholarly type, this journal invites case studies that take the form of presentations of practice—including documentation of socially-engaged practices and exegeses analyzing the effects of those practices.

The International Journal of Interdisciplinary Social and Community Studies is a peer-reviewed scholarly journal.

ISSN 2324-7576