1. Intro to Substance Misuse Prevention: Key Concepts
These slides were taken from the Substance Abuse Prevention Skills Training (SAPST) that was developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract. Reference #

2. Continuum of Care5
Draw the continuum of care5 model on easel paper so that you have it to refer to throughout the training.
Refer participants to Information Sheet 1.6: The Continuum of Care.
Make the following overview statements:
This model was first presented by the Institute of Medicine in 1994 as the mental health intervention spectrum, and it was expanded in 2009 to include promotion.
The continuum of care describes the scope of behavioral health services for individuals before, during, and after they experience a behavioral health problem or disorder. It includes promotion, prevention, treatment, and maintenance.
The continuum segments the need for care and the type of care required from various parts of the health care system. This means there are multiple opportunities for addressing behavioral health problems.
The continuum underscores the interrelationship among promotion, prevention, treatment, and maintenance. While some services may be more specific, individualized, or costly than others, it shows that each phase along the continuum does not exist in isolation.
Ask participants to raise their hands if they have seen the continuum of care diagram before.
_______________
Image reprinted with permission from the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.
Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract captus.samhsa.gov

3. Universal, Selective, Indicated
Explain that this pyramid provides a visual image showing the size of the populations served by prevention interventions:
Universal focuses on the entire population.
[In slideshow, click 1 time for Selective triangle to appear.] Selective focuses on a small part of the population.
[Click again for Indicated triangle to appear.] Indicated focuses on an even smaller part of the population.
Write definitions on a sheet of easel paper. If some participants have advanced knowledge, consider asking if anyone would like to try to explain universal, selective, and indicated interventions.
Universal preventive interventions take the broadest approach, and focus on “the general public or a whole population that has not been identified on the basis of…risk.”11 Universal prevention interventions might be in schools, whole communities, or workplaces. 
Ask participants:
What are some examples of universal strategies? (e.g., community policies that encourage access to early childhood education, implementation or enforcement of anti-bullying policies in schools, education for physicians on prescription drug misuse)
Selective preventive interventions are for “individuals or a population sub-group whose risk of developing mental disorders [or substance abuse disorders] is significantly higher than average.”12 Selective interventions focus on biological, psychological, or social risk factors that are more prominent among high-risk groups than among the wider population.
What are examples of situations that could put an individual more at risk? Emphasize the importance of checking assumptions about what puts people at risk. For example, children of single parents are not any more at risk for substance abuse than children of two parent households. (What puts people at risk will be covered in more detail later in the training.)
What are examples of interventions for selective populations? (e.g., prevention education for families living in poverty with young children, and peer support groups for people with a history of family mental illness and/or substance abuse)
Indicated preventive interventions are for “high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing mental, emotional, or behavioral disorder.”13 These interventions focus on the immediate risk and protective factors present in the environments surrounding individuals.
Knowing that selective interventions are for populations that are at risk, who do you think indicated interventions are for?
What are examples of interventions for indicated populations? (e.g., information and referral for young adults who violate campus or community policies on alcohol and drugs; screening, consultation, and referral for families of older adults admitted to emergency rooms with potential alcohol-related injuries)
INDICATED
SELECTIVE
UNIVERSAL

4. Strategic Prevention Framework
Step 1: Assessment
Assess problems and related behaviors
Prioritize problems (criteria: magnitude, time trend, severity, comparison)
Assess risk and protective factors
Step 2: Capacity
Assess capacity: Resources and readiness
Build capacity:
Increase resources and improve readiness
Step 3: Planning
Prioritize risk and protective factors (criteria: importance, changeability)
Select interventions (criteria: effectiveness, conceptual fit, practical fit)
Develop a comprehensive plan that aligns with the Logic Model
Step 4: Implementa- tion
Build capacity and mobilize support
Carry out interventions
Balance fidelity with necessary adaptations
Monitor, evaluate, and adjust
Step 5: Evaluation
Conduct process evaluation
Conduct outcome evaluation
Recommend improvements and make mid-course corrections
Report evaluation results
Link back to sustainability by asking participants what they think evaluation has to do with sustainability. Make the point that following the SPF steps actually leads to sustainability.
Revisit the Strategic Prevention Framework. Ask participants for the key tasks in each step. Refer participants to the Information Sheet 4.9: SAMHSA’s Strategic Prevention Framework: At-A-Glance and review each SPF Step. The graphic on this slide is in the handout.
Make the following summarizing points:
The SPF is a circular process, not a linear process.
Evaluation brings communities right back around to reassessment to find out whether their interventions are making a difference in preventing substance abuse and promoting wellness in the communities where they work.
Cultural competence - It’s vital that communities stay committed to being respectful and responsive to cultural issues at every step of the SPF.
The best way for communities to assure that their assessment, planning, implementation, and evaluation processes and tools are culturally relevant is to involve the populations that are the focus of their interventions in each and every step.
Sustainability is about sustaining positive outcomes and strengthening the overall community plan for addressing behavioral health problems.
- Community partners and stakeholders contribute to sustainability by:
Being knowledgeable about community mental, emotional, and behavioral health issues, including substance use and abuse
Being involved in and supporting prevention and wellness efforts
Incorporating prevention and wellness in their own work
Advocating for prevention and wellness with community leaders
Tell participants that through this training they have learned the basics of the SPF. They will need additional training on the SPF to learn about each step in more detail.
Information Sheet 4.9: SAMHSA’s Strategic Prevention Framework At-A-Glance

5. The nature and extent of substance use problems and related behaviors
What to Assess
The existing resources and readiness of the community to address its problems
The risk and protective factors that influence these problems and behaviors
The nature and extent of substance use problems and related behaviors
Explain what the assessment involves:
[In slideshow, this copy will automatically appear when you come to this slide] The nature and extent of substance use problems and related behaviors
[Click for this copy to appear] The risk and protective factors that influence or contribute to these substance use problems and related behaviors Risk and protective factors can be found at different levels, such as individual, peer, family, and community, and they can be measured using both quantitative and qualitative data. There are many ways to organize and compare the data you gather in order to help you prioritize them. Examples of R+P factors:
Risk factors for underage alcohol consumption: Low perception of risk or harm, ineffective family management or parental monitoring, youth social and commercial access.
Protective factors for underage alcohol consumption: Effective family management techniques, positive school climate, strong retail compliance policies in community
[Click a second time for this copy to appear] The existing resources and readiness of the community to address its substance use problems (in this training you will learn about it in Step 2)
Make the following point:
Substance use problems and related behaviors cannot always be changed directly, so with the SPF we will focus instead on addressing the underlying risk and protective factors for the problem and behaviors.

6. Logic Model – Next Stop on Our Road Map
Resources and Readiness
Problems and Related Behaviors
Risk and Protective Factors
Interventions
Explain that after communities collect the data on the problems and related behaviors, next they will need to decide which problems are a priority to address.
Connect this to the logic model by explaining that the “road map” is called a logic model. It is a logical way to (1) connect the problems identified by communities, (2) the specific factors in their community that are influencing or contributing to the problems, and (3) the interventions they will use to address the problems. Because this logic model provides a map of the process, it will be referred to through each step of the SPF.
Once the priority problem is identified, communities need to assess the risk and protective factors that influence that problem locally.
Assessing risk and protective factors is vital because you cannot change a substance abuse problem directly. Instead you need to work through the underlying risk and protective factors.
Ask participants what they remember about risk and protective factors from the first day and have each person share one thing (everyone must each share one thing that hasn’t already been shared—you may want to write what people shared on easel paper to make sure they don’t repeat).
Remind participants of the following key points from the first day of the training:
Risk and protective factors exist in individual, family, school/community, and societal contexts.
Risk and protective factors are present in various developmental periods.
Some risk and protective factors overlap with multiple behavioral health problems and developmental periods.
Reducing risk factors and enhancing protective factors helps prevent behavioral health problems and promote well-being.

7. Building Capacity Involves…?
Increasing Resources
Improving Readiness
[In slideshow, the image automatically appears when you come to the slide]
Explain that once a community’s capacity to do prevention is assessed, the focus shifts to building capacity:
Building capacity involves increasing the resources and improving the community’s readiness to do prevention.
Building resources and readiness often go hand-in-hand—in many cases, building resource capacity also contributes to greater community readiness. For example, when key stakeholders are engaged in solving problems, they often mobilize other community members to get involved. This leads to more people recognizing the value of prevention and being ready to take action.
This section will cover three ways to increase resources and improve readiness:
Engage stakeholders
Strengthen collaborative groups/partnerships
Raise awareness
Refer participants to the Information Sheet 3.1: Building Capacity and let them know that all of this information will be discussed in the following slides.
Information Sheet 3.1: Building Capacity

8. Levels of Involvement1 Collaboration Coordination Cooperation
Emphasize that when engaging in any prevention planning process to remember that the purpose in collaborating and involving others is for reaching an ultimate goal, such as reducing alcohol use among adults. In addition, different stakeholders and community sectors will want to (and need to) be involved at different levels.
Ask if any participants can provide an example of being involved in a group that lost sight of its goal and was just meeting for the sake of meeting.
Explain the different levels of involvement: networking, cooperation, coordination, and collaboration.1 Refer to the second page of Information Sheet 3.1: Building Capacity
Ask participants:
Who might be involved at the networking, cooperation, and coordination levels, and who might be a full collaborator if the goal is to reduce underage drinking?
At what level of involvement would you want the specific population group that the intervention will serve? For example, if the problem in the community is prescription drug abuse among older adults, then how could this population group (older adults) be involved in prevention? What would it look like?
What do you do if someone won’t come to your meetings? (Make sure the point is made that you need to get a seat at their table—attend their meetings and participate in their efforts.)
OPTIONAL Activity – Levels of Involvement
Time – 15 minutes
Instructions –
Put tape on floor in the shape of steps (five steps), and label each of the five steps one of the different levels of involvement.
Have participants select a problem (e.g. underage drinking).
Assign stakeholder roles to individual participants by giving them a sticky note with a role on it from the previous slide. To anchor this activity in the case study, consider using stakeholder groups identified in the case study activity in Session 2, Worksheet 2.11, Case Study Activity – Determining Resources & Readiness.
Ask the group of participants who are not in stakeholder roles to place each stakeholder at the level they’d like them to be (level of involvement). The individuals representing each stakeholder will need to move to their assigned step on the floor.
Then ask participants where the stakeholders really are (versus where participants would like them to be), and have the stakeholders move to that step (level of involvement) on the floor.
Ask participants how they might move the stakeholders from where they are to where participants want them to be (e.g., use other stakeholders to help engage them). You may want to move stakeholders around during this discussion about building capacity through engaging stakeholders and involving them at the most optimum level of involvement.
Collaboration
Coordination
Cooperation
Networking
No Involvement

9. Shared Decision-Making
Which option makes sense for a coalition?
Autocratic - One person decides
Consultative - Autocratic with advice from others
Minority - Expert, or those with vested interest
Majority - Voting
Consensus - Loyal minority agree to support majority
Unanimity - Everyone totally agrees
These are different models for decision making, every cluster is different but ideally you want a shared decision-making process that involves cluster representatives such as majority/consensus/unanimity. There are benefits of each – long term sustainability and ownership by working and making decisions together using a more shared-decision making process. Address nuance of decision-making, different scenarios depending on the task – financial at some points may need a more consultative process as contracts and funders are involved whereas decisions on the strategic plan IVs/strategy selection for the whole cluster ideally would want to involve key decision-makers and stakeholders to elicit their valuable input but also to gain their trust and buy-in for sustainability of strategy implementation.
Autocratic
(One person decides)
Fastest
Good in crisis
Less likely to be wisest decision
Less likely to be accepted unless survival is at stake
Consultative
(Autocratic with advice from others)
Fast
More ideas and information
Takes more time
Less chance of acceptance and commitment by others
Minority
(Expert, or those with vested interest)
Decision by “experts”
Faster than whole group
All points of view not necessarily heard
Not necessarily representative
Majority
(Voting)
Can be used with any size group
 Most people know this process
 Win/lose mentality
Lack of commitment by losers
Issues become personalized
Consensus
(Loyal minority agree to support majority)
Better decision
All opinions aired
Promotes synthesis of ideas
Elicits more commitment
Consistent with attunement concept
Requires mature members
Progress can be blocked by one person
Best in small groups…difficult in large groups
Can end up operating on lowest common denominator
Unanimity
(Everyone totally agrees)
Most comfortable
Almost impossible to achieve with more than two people

10. Example: Underage Drinking
Risk and Protective Factors
Interventions
Problems and Related Behaviors
Short-term Outcomes
Long-term Outcomes
Use the example on the slide of short- and long-term outcome for underage drinking with the risk factor of retail access and connect it to the logic model:
The interventions selected were compliance checks and merchant education.
The short-term outcome they want to achieve is to reduce the number of underage youth purchasing alcohol. Connect it to the interventions.
The long-term outcome they want to achieve is to reduce the percentage of underage youth who had at least one drink in the past 30 days (i.e., current use). Notice that the long-term outcomes relate directly to the behavior/related problems (underage drinking).
Underage drinking
(Short-term)
Reduce the number of sales to minors
(Long-term)
Reduce underage current use
Retail access
Compliance checks
Merchant education