Maine Learning Community: Selecting Strategies February 21, 2007 Maine Office of Substance Abuse (OSA) Northeast Center for Application of Prevention Technologies (NECAPT) Hornby Zeller Associates, Inc (HZA) Maine’s Environmental Substance Abuse Prevention Center (MESAP) Opening Remarks: This training was designed with partners to pick up where your assessments leave off Lots of opportunity for cross sharing Lots of time within county to work through activities that will help in strategy selection Provide you with the tools and resources (human and technical) to complete your plan This is day one and day two will be in March Opening Activity: What are you hoping to get out of today? Ask some participants to share aloud OR have all write expectations down on index cards. Facilitators collect and summarize after State presentation.

Learning Objectives By the end of day one workshop, participants will be able to: Better understand the Maine SPF-SIG initiative Follow a process to prioritize intervening variables Identify effective types of strategies to address intervening variables Apply criteria to determine “fit” of strategies Use resources to develop a comprehensive approach

Agenda Welcome and Introductions Past, Present, Future… State update Grantee check-in Prioritizing Intervening Variables Process for prioritizing Group work Identifying and Selecting Strategies Evidence-based interventions Determining “Fit” Creating a comprehensive approach

ME Office Substance Abuse (OSA) Update Review state assessment process Discuss timeline for SPF-SIG Rebecca will provide slides for this section

Common Terms Intervening Variables Consequence and Consumption (Risk & Protective Factors/ Underlying Conditions) Consequence and Consumption Patterns Evidence-Based Interventions Clarification of language Goals Objectives Strategies

Needs Assessment Process In addition to the needs assessment, communities completed a capacity assessment to assess human technical organizational and financial resources necessary to monitor affected populations *Maine’s SPF Guide to Assessment and Planning August 2006, Hornby Zeller Associates, Inc. This is the process that communities are involved in now

Needs Assessment Check-in What new partners or resources did you identify in your community as a result of your assessment efforts? What has been challenging? Was there anything that surprised you? Have tables spend about 5 minutes in small groups to discuss. Determine who will report out, then in large group report out one lesson learned so far - Ask for volunteers to report out on some interesting lessons learned or surprises Adapted from*NM Capacity Training, January 25, 2006, Michelle Fry & Paula Feathers, Southwest Center for Applied Prevention Technologies

Strategic Plan Elements Community Vision, Target Areas, Planning Process, Decision Process, and Prioritization (Prioritization – focus of Day One) Strategies (focus of Day One) Capacity Building Priorities, Action Plan, Sustainability (focus of Day Two)

Intervening Variables Prioritization ME Logic Models Intervening Variables and Contributing Factors Prioritization of Intervening Variables

Underage Drinking Logic Model Consequence and Consumption Patterns Intervening Variables Strategies Access/ Availability Parental Monitoring Underage Drinking Law Enforcement Knowledge of Health Risks *Access/ Availability – social and retail Need to define intervening variables and provide as a handout Advertising Adult Modeling School Policies

High-Risk Drinking Logic Model Consequence and Consumption Patterns Intervening Variables Strategies Knowledge of Health Risks High-Risk Drinking 18-25 yr olds Promotions & Pricing Need to define intervening variables and provide as a handout Retail Sales/ Over-service Lack of Screening/ Early Intervention

Prescription Drug Misuse Logic Model Consequence and Consumption Patterns Intervening Variables Strategies Knowledge of Health Risks Prescription Drug Misuse 18-25 yr olds Need to define intervening variables and provide as a handout Availability

Logic Model Table Discussion Looking at the logic model handouts: Do the problems and intervening variables seem to be consistent with what you found in your needs assessment? Is there anything that seems to be missing?

Underage Drinking Intervening Variables Retail Access/Availability Social Access/Availability Law Enforcement Parental Monitoring Knowledge of Health Risk Advertising Adult Modeling School Policies SPF is built on the idea that making changes to intervening variables at the community level will cause changes in substance use and related problems. For example: The above list represents the intervening variables already identified as priorities in Underage Drinking in the State needs assessment *Maine’s SPF Guide to Assessment and Planning August 2006, Hornby Zeller Associates, Inc.

Contributing Factors: Retail Access Retail Outlet Density ID Checks In Bars/ Restaurants Retail Access/ Availability Each intervening variable has different factors associated with it. For example: under Easy Retail Access, you may find that every convenience store sells alcohol, and there are bars that allow 18 to party 21 to drink w/out a real deterrent for the underage drinkers, alcohol sold all night in liquor stores. Enforcement of Minimum Drinking Legal Age (MDLA) Hours/ Days of Retail Sales

Youth Alcohol Use Underage Drinking School Policy Social Access Retail Access Law Enforcement Advertising Adult Modeling Parental Monitoring - MAKE LIST A HANDOUT of all contributing factors The rest of the intervening variables have their contributing factors as well. All of these contribute to the use patterns you have also found in your assessment. This use, ultimately contributes to the priority problem (underage drinking among high school youth). Of course all communities will not be able to address all the contributing factors for all intervening variables, therefore communities will need to prioritize the intervening variables most relevant to each community Youth Alcohol Use Underage Drinking

OSA Prioritization Process Changeability High Low Importance High Low The state went through a prioritization process to determine which intervening variables they included in the state logic model based on these criteria: Changeability – Do we have the expertise and know how (research knowledge) to change this intervening variable? Importance – How important is this intervening variable in impacting the problem across the state? Changeability – Do we have the expertise and research knowledge to change this intervening variable? Importance – How important is this intervening variable in impacting the problem across the state?

Community Prioritization Process Changeability High Low Importance High Low Community can engage in a similar process using slightly different definitions for the criteria: Changeability – Do we have the capacity (readiness and readiness) to change this intervening variable? Importance – How important is this intervening variable in impacting the problem in our community? Changeability – Do we have the capacity (resources and readiness) to change this intervening variable? Importance – How important is this intervening variable in impacting the problem in our community?

Prioritization Activity Each community group will be assigned one intervening variable (or contributing factor) for underage drinking Use the data that you have brought and your knowledge of the community to answer the questions in the prioritization table Come to a consensus on the importance and changeability of that variable (high/low) Activity – Using the Prioritization handout In community groups, work through the intervening variable (or a key contributing factor) assigned to your group. Based on your own data and analyses or your knowledge of your community to complete the grid to determine whether importance and changeability are high or low.

Underage Drinking Logic Model Consequence and Consumption Patterns Intervening Variables Strategies Access/ Availability Parental Monitoring Underage Drinking Law Enforcement Knowledge of Health Risks Advertising Adult Modeling School Policies

Constructing a Matrix Activity Changeability High Low Importance High Low Then groups will report out and facilitator will complete a giant 2X2 on newsprint with the intervening variables in their designated quadrant. Using the newsprint 2X2 table facilitator will fill in the quadrants with the intervening variables Next, the large group will look at the giant 2X2 table and as decision makers in this composite community to determine which intervening variables will become the priorities – Discuss pros and cons for choosing high importance/ low changeability or low importance/ high changeability If all are high/high- what other elements would you need to consider to prioritize? Would need to compare/contrast variable to eachother instead of looking only at one. This process is one that can be replicated with needs assessment and capacity assessment data to prioritize in communities.

Logic Model Strategy Consequence and Consumption Patterns Strategy Intervening Variable Strategy Consequence and Consumption Patterns Intervening Variable Strategy Strategy Intervening Variable

Identifying and Selecting Evidence-Based Interventions (EBIs) Large group: How are strategies selected? Give examples (what has been done in the past? What know how to do? New interesting program? Connections that we have?) Why not continue to select strategies in that way? State wide approach Based on needs of community/ target audience Notes: At this point, you have assessed your needs and resources, know what capacities you have and what resources need to be increased, now you are ready to move into planning and selecting effective strategies. How do you know what to do? There are many programs out there that have shown to be effective with various groups of youth, parents, and communities. Check out the Samhsa website for this information. Remember CSAP also knows that there are many strategies that are “home grown” and occur in various communities around the country. They are trying to cultivate and disseminate these strategies through the process called, NREPP. (brief description)

High-Risk Drinking Logic Model Consequence and Consumption Patterns Intervening Variables Strategies Knowledge of Health Risks High-Risk Drinking 18-25 yr olds Promotions & Pricing Consider this example of high risk drinking Retail Sales/ Over-service Lack of Screening/ Early Intervention

Strategy Match Low price alcohol specials in bars Over-service of young adults Consequence and Consumption: High-Risk Drinking 18-25 yr olds Middle school curriculum Mentoring Program If you are trying to impact “intervening variable” and ultimately the “consequence” then strategies must match These strategies do not match Ask what intervening variables may the strategies shown impact?

Strategy Match Low price alcohol specials in bars Over-service of young adults Consequence: Underage Drinking Consumption: Underage and Young adult binge drinking Policy to limit drink specials Responsible Server Education

Selecting Best Fit Prevention Interventions Identify Types of Strategies Select Specific Programs, Practices & Policies Ensure Effectiveness Best Fit Prevention Interventions Demonstrate Evidence of Effectiveness Demonstrate Practical Fit Demonstrate Conceptual Fit Relevant? Practical? Effective?

Conceptual Fit A “Good Conceptual Fit” intervention should: Fit into community logic model Drive positive outcomes in identified substance abuse problems Address the community’s intervening variables Be based on evidence-based principles for target population Target multiple opportunities for intervention If question to ask yourself is “Is the type of strategy relevant”?

Types of Strategies Policy Enforcement Communication Collaboration Education Define strategies Small group activity – with one of the 3 logic models, begin thinking through potential types of strategies that may conceptually fit

Practical Fit for Community Feasible given a community’s resources, capacities, and readiness to act Add to or reinforce prevention strategies in the community—synergism and layering Consider community climate Meet cultural needs of target population Sustainable in community Saturation Next criteria is practical fit – Can your organization do this in your community?

Practical Fit Activity Assess how well the strategy practically fits your community: Does your coalition have the staff and funding needed? Do you have the necessary community contacts needed (police, leaders, etc.)? Will the community support this strategy? Does strategy reflect our community’s culture? Could this strategy be sustained? Activity – Use prescription drug use logic model********* All groups will be given a strategy that addresses the same intervening variable. Assuming that you have decided to address [intervening variable] and the strategy your group has been assigned conceptually meets your need – fits into your logic model. Is that strategy practical? Groups will answer the discussion questions to determine how well that strategy would fit in their community. Ask groups to briefly report out on how practical the strategy could be for their community Back up activity – ask tables to discuss which questions do they find themselves asking the most often regarding strategy selection in general Make a handout

Prescription Drug Misuse Logic Model Types of Strategies Consequence and Consumption Patterns Intervening Variables Knowledge of Health Risks Prescription Drug Misuse 18-25 yr olds Need to define intervening variables and provide as a handout Availability

Effectiveness Definition of Evidence-Based Interventions Finding Evidence-Based Interventions Creating a Comprehensive Approach

Paradigm Shift From picking off lists to thinking critically about needs From categorical labels to ratings along a continuum From relying on strength of evidence alone to assessing the relative importance of strength of evidence in a broader context From stand-alone intervention selections to comprehensive community plans CSAP process to expand the field of potential strategies Expert Workgroup on Evidence-Based Programming Convene nationally recognized prevention researchers—diverse theoretical backgrounds and perspectives Develop recommendations and guidelines for prevention planners—SPF SIG Program Need broad array of evidence-based interventions, and Flexibility to choose options that fit community circumstances

What is Evidence-Based? Included on Federal lists or registries of evidence-based interventions Reported (with positive effects) in peer-reviewed journals, or 3) Documented evidence of effectiveness based on guidelines developed by SAMHSA/CSAP Workgroup decided on guidelines to assist in process of identifying strategies (not a new list) …

What is Evidence-Based? (con’t) Guidelines for Documenting Effectiveness Based in solid theory validated by research Supported by a documented body of knowledge generated from similar or related effective intervention Judged by informed experts to be effective Informed experts could include state level group OR key community prevention leaders and/ or elders, or other respected learders within indigenous cultures.

How do you find Evidence-Based Interventions? Federal Registries CAPT Resources Experts in the field (NIAAA, NIDA) Research This info will also be a handout

Definition of Peer-Reviewed Journals Scientific journals in which submissions are reviewed and selected for publication by panels of experts in the field In the case of proposed publications, an editor sends advance copies of an author's work or ideas to researchers or scholars who are experts in the field (known as "referees" or "reviewers"), normally by e-mail or through a web-based manuscript processing system. Usually, there are two or three referees. These referees each return an evaluation of the work to the editor, including suggestions for improvement. Typically, most of the referees' comments are eventually seen by the author. Scientific journals observe this convention universally. The editor, usually themselves understanding the field of the manuscript (although not in as much depth as the referees who are specialists), then evaluates the referees' comments, their own opinion of the manuscript, and the context of the scope of the journal or level of the book and readership, before passing a decision back to the author(s), usually with the referees' comments. Referees' evaluations usually include an explicit recommendation of what to do with the manuscript or proposal, often chosen from a menu provided by the journal or funding agency. Most recommendations are along the lines of the following: to unconditionally accept the manuscript or proposal, to accept it in the event that its authors improve it in certain ways, to reject it, but encourage revision and invite resubmission, to reject it outright. During this process, the role of the referees is advisory, and the editor is under no formal obligation to accept the opinions of the referees. Furthermore, in scientific publication, the referees do not act as a group, do not communicate with each other, and typically are not aware of each other's identities. There is usually no requirement that the referees achieve consensus. Thus the group dynamics are substantially different from that of a jury. In situations where the referees disagree about the quality of a work, there are a number of strategies for reaching a decision. When an editor receives very positive and very negative reviews for the same manuscript, the editor often will solicit one or more additional reviews as a tie-breaker. As another strategy in the case of ties, editors may invite authors to reply to a referee's criticisms and permit a compelling rebuttal to break the tie. If an editor does not feel confident to weigh the persuasiveness of a rebuttal, the editor may solicit a response from the referee who made the original criticism. In rare instances, an editor will convey communications back and forth between authors and a referee, in effect allowing them to debate a point. Even in these cases, however, editors do not allow referees to confer with each other, and the goal of the process is explicitly not to reach consensus or to convince anyone to change their opinions. Some medical journals, however (usually following the open access model), have begun posting on the Internet the pre-publication history of each individual article, from the original submission to reviewers' reports, authors' comments, and revised manuscripts. Traditionally reviewers would remain anonymous to the authors, but this is slowly changing. In some academic fields most journals now offer the reviewer the option of remaining anonymous or not, or a referee may opt to sign a review, thereby relinquishing anonymity. Published papers sometimes contain, in the acknowledgements section, thanks to anonymous or named referees who helped improve the paper. Johns Hopkins School of Public Health

Using Peer-Reviewed Journals Questions to consider when matching your community (conceptual fit, practical fit, effectiveness): Was the program, practice, or policy implemented in a similar geographic area? Was effectiveness documented in similar subgroups (such as race/ethnicity, sexual orientation, high school dropouts, age, gender)? Does strategy show effectiveness in impacting your selected intervening variable(s)? Does the study adequately rule out competing explanations for the findings?

How to Find Articles Google Scholar http://scholar.google.com/ Google scholar allows you to search for books and journal articles

Google Scholar Results For example if you are interested in the research that supports responsible beverage service, you can go to this website type in “responsible beverage service” and you will come up with 329 articles that talk about this program When seeing the number of results you can think about defining your search even more, for example search responsible beverage service in bars. Also keep in mind that the first articles to appear are usually the most relevant, so consider looking through the first 20 articles to find what you need.

Developing a Comprehensive Approach Use multiple interconnected strategies in order to reach community level change Multiple strategies will complement and reinforce each other Consider number of people impacted in each strategy

Ecological Model Target multiple domains or contexts across the lifespan

Underage Drinking Logic Model Consequence and Consumption Patterns Intervening Variables Strategies Social Host Liability Policy Underage Drinking Social Access/ Availability ??? Let’s address social access to alcohol contributing to underage drinking Community needs assessment identified that youth were accessing alcohol through parents and community decided to work toward having the town implement a social host liability policy. Small group discussion: What are some complementary strategies? ??? ???

Underage Drinking Logic Model Consequence and Consumption Patterns Intervening Variables Strategies Social Host Liability Policy Enforcement of social Host liability policy Underage Drinking Social Access/ Availability Let’s address social access to alcohol contributing to underage drinking Here are some examples of complementary strategies Communication: Social Marketing Campaign Collaboration: Police and Community Parent groups

Reach of Strategies How many people will your interventions impact? Which sectors of the community will be impacted by your efforts? What dosage of the interventions will target audience experience? Saturation of your area – Instead of lots of strategies around one small group but moving toward population level change need to impact various sectors of community and reach many people Population level change – community level change (community defined) underage population in your community not 6th graders in one school Tool in binder to assess reach of all your strategies.

Summary of Things to Consider Conceptual fit Practical fit Effectiveness Comprehensive approach Reach There are lots of things to consider here is a summary.

Maine Learning Community: Implementing and Sustaining Efforts March 26, 2007 Augusta, ME Agenda Implementation core components Environmental strategies Building capacity Sustainability & funding sources OSA will have opportunity to suggest what communities can do before then to prepare