Evidence-Based Prevention - Community Prevention Initiative (CPI)

ObjectivesIdentification of opportunities to promote andelevate alcohol and drug prevention effortswithin the broader prevention dialogueIdentification of the linkages between alcoholand drug prevention and prevention of otherkey topical issuesRecommendations for ensuring that alcoholand drug prevention is considered in thedevelopment of comprehensive prevention andwellness efforts statewide and nationally2

3A Model for Social Change:Collective Impact

Summit PrinciplesSeekInnovatePropelStretchContributeBuildCollaborate4

A Call to Action

Moving Prevention to theForefront: Action Under WayJacquolyn Duerr, MPHCalifornia Department of Public HealthChronic Disease and Injury Control DivisionSafe and Active Communities BranchFebruary 2013

Causes of Death,California, 2007Allother,23%Tobacco, poor diet, andphysical inactivity top 3causes of deaths;; alcohol is4 th leading cause of deathInjuries are leading cause ofdeath for people ages 1-44Injury,8%Chronicdisease,69%Inequities exist across healthoutcomes• Income, education,race/ethnicityObesity rates high, threatenlife expectancySource: 2007 Death Statistical Master File

Costs of Chronic Disease in CATreatmentExpendituresLostProductivity2003 2023(Projected)$27B $72B$106B $359BTotal $133B $431BMilken Institute - based on MEPS/NHISMore than 96 cents of everydollar spent 83 cents of every dollarspent in Medicaid3

Community PrescriptionSource: Bobby Milstein, Jack Homer, Peter Briss, Deron Burton and Terry Pechacek. Why Behavioral and Environmental Interventions areNeeded to Improve Health at Lower Cost. Health Affairs, 30, no 5 (2011): 823-832

Community PrescriptionSource: Bobby Milstein, Jack Homer, Peter Briss, Deron Burton and Terry Pechacek. Why Behavioral and Environmental Interventions areNeeded to Improve Health at Lower Cost. Health Affairs, 30, no 5 (2011): 823-832


What Else is Going On?

Potential Areas ofIntegrationDensityLabelingExternal signsLicensingDiscountsPackage size

What Does Integration Mean? Working together where it makessense at the local level Creating efficiencies Finding flexibility in funding Leveraging community will andattention Promoting systems change

Integrated Campaign GoalTo improve the healthof Californiansthrough changes tothe retailenvironment.

What is Next? Retail Environment Training: September2012 Retail Campaign Data Collection Training:May 2013 LLAs Train Data Gatherers: May-June2013 Local Data Collection: July-August 2013 Advanced Data Analysis Webinar:January 2014 Local Public Intercept/Key InformantInterviews: February-June 2014

Possible Areas to ExploreRetail outlets and zoning: Links between alcoholand healthy food accessEducation: Links between attendance rates,overall health outcomes, and alcohol abuseCommunity safety: Links between liquor outletdensity and violenceTransportation: Links between traffic-relatedinjuries and deaths and alcohol, includingpedestrian and bicyclist safetyBuilt environment: Links between neighborhoodcharacteristics and alcohol consumption

Near Term ChallengesMoving into a clinical service delivery environmentIntegration of substance use disorder treatment withprimary careIncrease knowledge/understanding of health behaviors:e.g., alcohol use problems, injection drug use (needles),unprotected sex, and smokingSocial environment or social characteristics: e.g.,discrimination, income, and genderPhysical environment or total ecology: e.g., where aperson lives, poor housing, and neighborhoodretail/marketingHealth services/medical care infrastructure developmentand funding dominates the health agenda

1 st Put Prevention First2 nd - Do It In Concert Stop the problem before itcreates/amplifies risk and vulnerability Prevention $ not growing;; less than 2% of overallhealth budget and Working together is one way to do more with less We cannot treat our way to health Community/stakeholders do not work in silos;; theyfocus on nearby/cross cutting concerns Same solution solves multiple problems Youth get it!

Make Prevention Priority#11. Put prevention in your workplan-daily, weekly, and 1,2,3,4, and 5 year.2. Shift what you measureand count for success3. Write and fill the communityprescription


A Conversation with Leaders in the Field

Prevention Perspectives: AConversation with Leaders in the FieldSome Reflections of an Applied ScientistSteve Wirtz, Ph.D.Safe and Active Communities BranchCalifornia Department of Public Health(slides from multiple sources)Power of Prevention SummitFebruary 6th & 7th, 2013Sacramento, California

Questions for Consideration• What do we mean by prevention?• What are we trying to prevent?• How does prevention fit into the broadersocial context?• Does prevention work?• What evidence based approaches, strategiesand practices are available?• How can we achieve collective impact?

What Do We Mean by Prevention?• Universal Selective Indicated• Challenges Behavioral Health Health Care Reform• Public Health Field Primary Secondary Tertiary

Public Health Approach• Primary prevention• Population based• Environmental policies, laws & social normchange

Haddon MatrixPhase Humans Agent orVectorPre-event PrimaryPreventionStopping the event from occurringby acting on its causes.Event - SecondaryPreventionAttempting to prevent or reduce theseriousness of the event when itactually occurs by designing andimplementing protectivemechanisms.Post-event - TertiaryPrevention(Treatment and Rehabilitation)Attempt to reduce the seriousnessof the consequences immediatelyafter an event by providing adequatecare and over the longer termworking to stabilize, repair andrestore functioning.PhysicalEnvironmentSocialEnvironment

What are we trying to prevent inthe SUD field?• Substance Use Disorders (abuse & dependence) DSM-V - a single dimension of substance problemsoccurring on a continuum compulsive pattern of substance use physical tolerance and withdrawal symptoms are only 2 of 11criteria• Consequences of substance use Underage, illicit, and excessive use & misuse Broader consequences of misuse and abuse, includingaddiction

Past-30-day alcohol use (any, binge,or heavy) by age.

Broader Context of Prevention• Life Course Perspective emphasizes atemporal and social perspective on healthand well being DevelopmentalAcross life experiences (i.e., gestation, earlychildhood, adolescence, young adulthood, midlife,senior)Across generations Socio-ecologicalPast and present experiences are shaped by thewider social, economic and cultural context.

Preventing Mental, Emotional, and Behavioral Disorders Among Young People:Progress and Possibilitieswww.nap.edu

Models of Life Course Impacts• Critical period model• Critical period model with later effectmodifiers• Accumulation of risk with independentand uncorrelated insults• Accumulation of risk with correlatedinsults Risk factors tend to cluster in socially patternedways Chains of risk or pathways over time

DeathEarlyDeathDisease, Disabilityand Social ProblemsAdoption ofHealth-risk BehaviorsScientificgapsSocial, Emotional, &Cognitive ImpairmentAdverse Childhood ExperiencesConception

Example of Cumulative Risks• A child living in adverse childhood socialcircumstances is more likely to be of low birthweight, and be exposed to poor diet, childhoodinfections and passive smoking.• These exposures may raise the risk of adultrespiratory disease.• Repeated respiratory disease in childhood mayresult in increased sick absence from school andlower educational attainment• This in turn, leads to a greater likelihood ofsmoking in adulthood and a manual occupationwith greater respiratory hazards.

Alcohol Abuse in the Homeand the Risk of Childhood Abuse504540Number of alcohol abusers:0 1 2 or morePercent Abused (%)35302520151050Emotional Physical SexualType of Abuse

Alcohol Abuse in the Home and the Riskof Other Household Exposures During ChildhoodHousehold factor (%)45403530252015105Number of alcohol abusers:0 1 2 or more0Mother treatedviolentlyMentalillnessDruguseSuicideattemptMemberimprisoned

ACE Score and IllicitDrug AbusePercent With Health Problem (%)1412108642ACE Score0 1 2 3 4 >=50Ever had adrug problemEver addictedto drugsEver injecteddrugs

Percent with alcohol relatedproblem403530252015105Alcohol Use and AbuseACE Score0 1 2 3 4 or more0Ever heavydrinkerProblem withalcohol useAlcoholicMarried anAlcoholic

Does prevention really work?• Tobacco control Policy, media, and program interventions usingcommunity coalitions in a comprehensive, multiplechannel, multiple target -smoking and other tobacco use Reduced smoking Reduced illness and health care expenditures• Drunk driving MADD and Law enforcement Policy and social norm change Enforcement• California cost benefit analysis - Ted Miller, PIRE• California cost savings - Ted Miller, PIRE

Underage Drinking:Evidence-based Theory of ChangeCompliance checks,citations, license lossRetailer Training &rewardsRetail Sale ofalcohol toyouth19UnderagedrinkinglawsLocalalcoholpolicyMedia advocacyVisibleenforcementParty patrol,Shoulder taps,Beer keg registrationCommunitynorms aboutyouth drinkingSocial availabilityof alcohol toyouth (parties,peers, families)UnderageDrinkingFamily, School, &Peer InfluenceLegal risks for providing alcohol to underage

Prevention Strategy Options• Individual Behavior and behaviorchange Relationship betweenindividuals and theiralcohol and drugrelatedproblems Short-term programs People remain focusedon self Individual as audience Professionals makethe decisions• Environmental Policy and policy change Social, political andeconomic context ofsubstance problems Long-term policydevelopment People gain power byacting collectively Individual as advocate Professionals help createavenues for citizens todevelop and expresstheir voice

Individually Focused PreventionStrategies• Assume that AOD problems are due to: Problems of individuals Lack of information about alcohol andother drugs Lack of knowledge about negativeconsequences Lack Inadequate attitudes and skills

An Environmental Perspective• Views AOD problems not as solelyindividual behavior, but also the collectivereflection of community norms and practices• Targets the social, physical or publicenvironments by managing locations andsettings where use and sales occur• Targets are policy makers and others withauthority to change environments• Seeks to change physical, economic, legaland social processes of communities

The Dialogue• Individual Targets at-risk and highriskindividuals to movethem into a lower riskcategory Secondary and TertiaryPrevention Problems present in thehealthcare setting, andthe opportunity forindividual interventionshould not be missed• Environmental Congruent with a PublicHealth model Behavior has anthat needs addressing Primary and SecondaryPrevention Problems present in acommunity setting, andthe opportunity forcollaborative interventionshould not be missed

Why work on environments?• Long term change• Affects entire community• Builds capacity• It works

The Role of Policy and Law:Changing the Focus of InterventionINDIVIDUALSPOPULATIONS

CHANGE IN POINT OF INTERVENTIONProducts/Availability/MarketingCosts/Alcohol TaxesIndividual CharacteristicsCommunity/EnvironmentalFactors

Policy Change TargetPopulation ScaleEntire PopulationMultiple SectorsSingle SectorIndividualEvidence-basedprogramsHealthcareSectorWorksiteSectorHealthyCommunitiesNeighborhoodCommunityStateNationalGeographic ScaleAdapted from YMCA Activate America presentation

Underage Drinking: A Critical Componentof the Alcohol Market• Underage drinking accounts for an estimated 20% ofthe alcohol beverage industry's sales -- $23.4 billionof the total $116.2 billion Americans spend onalcohol each year.• The earlier a young person begins to drink, theheavier his or her consumption is likely to be later inlife.

Evaluation• How do we know if we are succeeding withour prevention efforts?• Levels of analysis State County Provider• Program management and monitoring• Evaluation

Collective Impact• Large scale social change requires broadcross sector coordination Not enough to have isolated interventions ofindividual organizations• 5 Conditions of Collective Success Common agenda Shared measurement systems Mutually reinforcing activities Continuous communication Backbone support organization

AOD Prevention:There’s No Place Like HomeConsiderations on AOD prevention within variousorganizational structures7(e.g., Behavioral health, public health, health & human services, etc.)

CountyPlanningWho/what/where/why arecountiesmotivated todo effectiveAODprevention?PromotingPreventionWithinCountyInfrastructureFactors thatelevatepreventionWhat are our rolesin making thathappen(or maintaining it)?8

9Perspectives Near & Far


Gary Najarian, M.S.W.Project Manager, Community TransformationSan Francisco Department of Public Health

Stay ahead of thecurve Maintain ournetworks andconnections as a field Do more with lessand enjoy it

Cost Community Continuum of Care Care

Return on investment, savesmoney Allows for addressing bothon-going and emerging issues Example – reducing BMI

Commitment/orientation/willingness to be better Advance the science andevidence of prevention Try innovative things Professional development

Way to organize a framework for the health ofa community Strong focus on “place matters” Increased collaboration with new and diversepartners

Meaningful part of theContinuum of Care/Services Don’t “limit” prevention

Critical that the healthdepartment seesprevention as a part ofits role Affordable CareAct/National PreventionStrategy Healthy Places &Healthy People

Contact InformationGary Najarian, M.S.W.Project Manager, CommunityTransformationSan Francisco Department of Public Health(415) 581-­‐2459gary.najarian@sfdph.org

Opportunities to Advance California’sCapacity for Data-driven AOD Prevention• The current and the future of informed preventionefforts.• Are there technological or resource differentialsacross sectors/fields/regions that preventionleaders need to monitor, model, or address?20

21Perspectives Near & Far


• Successful Prevention in Different Contexts• Transitions & restructuring• Organizational structures (e.g., BH, PH, MH)• Affordable Care Act/Health Care Reform• Implications for prevention• Readiness23

• Workforce Development• Leadership Development• Policy Development & Support• Advocacy Efforts• Establishing Effectiveness• Partnerships• Securing Funding & Sustainability• Cultural & Linguistic Competence24

Lunch Activity 12-12:30• See 2 confirmed topics• Review potential topics• Propose any new topics on card provided12:30-1:00“Vote” for up to 3 topics25

Moving Prevention Forward

World Café: Discussion GroupsEach Discussion Group session lasts for 20 minutes.Use the opportunity to:a) discuss advancing this aspect of prevention, andb) integrate varying perspectivesParticipants are tasked with discussing and legibly recording the following: Short/long term vision Recommended action SummaryNotes may be taken on the flipchart; but the Session Worksheet must be completedduring the Summary portion of the session.Participants may either join up to 3 different Discussion Groups or remain for 2+ sessionswith the same Discussion Group.28

29Look for this handout:

30Look for this handout:

Selected Topics• ACA/HCR• Workforce & Leadership Development• Contexts of Prevention• Partnerships in Prevention• Policy Development & Support• Prevention Practices31

oving Further Forward

Reflection GroupFormationRepresentation from eachWC-I topic – that is, at leastone participant from each ofthe WC-I discussion groups.Use the color-coding on yourcard to confirm representationand identify who reports onwhat topic.Recruit from or trade withother groups as necessary.Identify the representativewho will function as a reporteron each topic.33

34Look for this handout:

5-minute Topic Report-outReporter prompts:• Summarize 1-3 key points made about thetopic (include diverse perspectives if therewere any)• Briefly describe 1-2 visions emerged fromthe discussion?• Provide short overview of 1-3 key actionsdiscussed as essential to the vision?35

Tomorrow is Today

Determine Prevention WorkgroupsTrendsConvergencesThemesOverlapsDisparities Intersections37

Day 1

Welcome to Day 2

Welcome to Day 2

Action PlanIdentify• Identify one or two issues or challenges facing your specific work group topic• Discuss and come to consensus about your recommendation for addressingthe issue or challengeDiscuss• Discuss and record at least one action item or next step for implementing therecommendation• Decide and record who is going to be responsible for taking that next stepImplement• Decide and record the timeframe for completing the next step• Make a note of how the person responsible is going to inform this work groupthat the next step has been taken (i.e., via email, phone call, newsletter, etc.)41

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Key MessagesIdentify one key messagespecific work group topic thatyou want to take back andshare with your constituents.Discuss and record what support youmight need to share or take action onthat key message with your constituents.Who might be able to provide you thatsupport? A supervisor? A funder? Acommunity based coalition?Discuss and record at least one actionitem or next step you can take forsharing or acting on that key messagewith your constituents.Discuss and record anyobstacles you might encounter insharing or taking action on thatkey message with yourconstituents. Lack of specificpolicy? Lack of funds? Lack ofpersonnel?Discuss and record what resourcesyou might need to share or takeaction on that key message withyour constituents. Will you need anew policy? Will you needsupervisor approval? Will you needfunding? Etc.45

Look for this handout:

Making It Happen

Look for this handout:

• Logistics• Action items• Support/Resources49

Putting It All Together

Reaching the Summit• The role of prevention leaders• Sustaining momentum51

Using Principles of CollectiveImpact to Ground your Work• Common Agenda: shared vision for change• Shared Measurement: collecting data andmeasurement results consistently• Mutually Reinforcing Activities: activities aredifferentiated while still being coordinated with acommon plan of action• Continuous Communication: consistent and opencommunication• Backbone Support: a separate organization with staffand skills to coordinate and support entire initiative52

Day 2

Center for Applied Research Solutions708 College Ave. Santa Rosa, CA(877) 568.4227 carsinfo@cars-rp.orgwww.cars-rp.orgwww.ca-cpi.org

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