Engs, Ruth C. [Ed.] Controversies in the Addiction's Field. Louis Gliksman and Cynthia Smythe. "Chapter 21: A review of school based drug education programs: Do we expect too much?"
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CHAPTER 21 A Review of School-Based Drug Education Programs: Do We Expect Too Much?
Louis Gliksman, Ph. D., Cynthia Smythe, M. Ed.
Concerns about alcohol and drug abuse have existed in our society for decades. In addition to trying to deal with the issue of treatment—how do we help those who Annie in trouble—we have also been concerned with the issue of prevention—how do we stop these problems from occurring in the first place. Most of the prevention efforts that have been developed over the years have focused on children in the school system—for the most part children who are in grades 6 and above. The reasons cited for the emphasis on this particular group are numerous. For example, we have heard that our children are our future and we must do whatever is necessary to ensure that they don't fall under the spell of drugs; and if we get to these kids before they use any drugs we increase the likelihood of success. In point of fact, one of the primary reasons for this emphasis is decidedly practical. It is easier to develop programs and implement them for this particular group because they are a captive audience. We know where to find them and how to convey information because that is what the school system has been doing for years. We have been following this approach blindly in spite of the questions and issues with which we have been confronted over the decades, the most fundamental of which is whether this programming approach is having the desired effect. While we have taken cursory looks at individual approaches and have changed approaches over the years, we have not really addressed the issues fundamental to this type of approach to prevention.
Drug prevention programs for school-aged children should generate a number of specific questions. For example, how effective is any one school program in preventing drug (i.e., alcohol, illicit drugs, and tobacco) abuse? Are programs methodologically sound enough for consumers to trust the
*'The views expressed in this document are those of the authors and do not necessarily reflect those of the Addiction Research Foundation.
results and act on them? Are there principles for effective programming that can be gleaned from the hundreds of programs developed and implemented thus far? Can programs alone or policies alone be effective in preventing use/abuse? These and other similar issues will be addressed by reviewing some of the more current literature on schoolbased programming. In order to put our discussion into perspective we will begin with a brief review of the history of school-based prevention programming. It should be remembered that many of the changes in the underlying philosophies of these approaches reflect the values of our society at that time probably more than they reflect the current state of knowledge about attitude and behavior change. We will focus primarily on alcohol and tobacco use among school-aged children and adolescents and will conclude our discussion by trying to make recommendations for future programming based on our interpretation of what went before.
An Historical Perspective of School-Based Programming
The following history of school-based alcohol programming is based partially on a 1976 review paper by Gail Milgram. Alcohol education in the U.S. has its roots in the history of the Temperance Movement which emerged in the 1840s. The movement urged all states to require teaching the "evils of alcohol" in school and by 1880 this was accomplished. It wasn't until the 1930s and the repeal of prohibition that alcohol education began to change. The objectives of alcohol education at that time were to stress abstinence during the growing period and then responsibility for substance use after growth had finished.
The decade of the 40s can be characterized by two opposing forces: evils of alcohol versus objective information. The first approach emphasized the extensive and serious damage done to health by alcohol. The latter approach stated that students were not to be scared into abstinence but were instead to be given simple facts based on scientific truths.
A change in the philosophy of alcohol education can be noted in the 50s. There are few references left to the evils of alcohol and many more to the teaching of scientific facts. There is also a move at this time toward alcohol education becoming part of a total health education curriculum. However analyses of curricula found that alcohol education was dealt with on a hit-or-miss basis and material was often inaccurate.
Alcohol education in the 60s favored the objective scientific approach It was felt that specific information and systematic instruction about alcohol was necessary to help students form a personal decision when older. It was in this decade that people became interested in the effect of teacher variables on students (i.e. how comfortable was the teacher when discussing these issues).
The 70s brought a potpourri of approaches: the ever present evils of alcohol; the concept of responsible drinking; a call for objective honest information; and a new movement for "alcohol is a drug approach." Analyses of alcohol education literature from this decade show that most education material was produced for teachers and college and high school students with little for elementary students. A review of curriculum guides shows little stress on alcohol and highway safety or teenage drinking.
This brings us to the 80s. In this decade the predominant approach based on the work of Fishbein and Ajzen (1975) incorporates the notion that attitudes are determinants of behavior and involves creating programs that will reduce abusive behavior by increasing knowledge and improving attitudes. A second approach that is quickly gaining popularity is the Social Influence model based on McGuire's (1964) social inoculation theory and Bandura's (1977) social learning theory. This model emphasises the external influences that push adolescents toward drug use particularly the media and key people in the adolescent's life. The approach acknowledges the vulnerability of adolescents by promoting such programs as "Just Say No" and Life Skills Training.
The drug education literature is rife with articles denouncing the effectiveness of the knowledge-attitude-behavior paradigm. However it is difficult to know whether the programs themselves are ineffective or the evaluations are so poor that any effects are masked. A few examples follow. Staulcup Kenward and Frigo (1979) reviewed 21 primary alcohol prevention projects and found no link between knowledge or attitude change and behavior change. The authors plead for better evaluations standardized measuring instruments and longitudinal studies.
Kinder, Pape and Walfish (1980) reviewed 25 studies and found knowledge gains but no attitude or behavior changes. They again plead for better methodology in the evaluations and for valid measures. Some tentative changes in attitudes and behavior in adult populations make the authors wonder if education should be directed toward specific populations using specific variables..
During this same period a review of 127 program evaluations was done by Schaps, DiBartolo, Moskowitz, Palley, and Churgin (1981) who found the programs generally ineffective. However when looking at the 10 best researched high intensity programs they found some positive effects.The authors suggest that the evaluations be more methodologically rigorous with program outcomes better linked to the actual program elements.
It appears that in the absence of positive effects the alternative has been to blame the methodology and not the program itself. This may be true but there is a real paucity of evidence to back this up.
However, these somewhat discouraging reviews also did lead to some philosophical papers about the nature of the knowledge-attitude-behavior paradigm itself; the value of these programs generally; the reasons for the limited success of most programs. In 1983 Weisheit published a paper about why programs fail. He believed abstinence-oriented programs of necessity failed since the large majority of teenagers drink. Because of this failure, the responsible use paradigm emerged. Theoretically, responsible use makes sense, but Weisheit claims it is hard to define and difficult to implement and evaluate clearly. Therefore, success is unlikely. Since most primary prevention fails with teenagers in any case, he suggests we use different markers of success than the conventional ones. A program may be deemed successful if it makes parents and taxpayers happy and the school feels it is doing its job.
Goodstadt (1986) cites five previous reviews that are consistent in their findings of little evidence of effectiveness. Because the evaluation methodology in these studies is inadequate and the results too inconsistent or negative, the findings are not helpful for future programming. He suggests several reasons for these results: programs may be thought to fail because the evaluations fail to assess differential effects on subgroups of the target audience; although knowledge is relatively easy to influence by many types of programs, attitudes and behaviors are extremely difficult to modify; drug education programs fail to provide links with other areas of school curriculum; too little emphasis is placed on implementation of the program and too little time spent delivering the program; and there is a failure to distinguish between process and outcome evaluation.
In 1984, Polich, Ellicksen, Reuter, and Kahan in a Rand report on adolescent drug use make a strong argument for the Social Influence model. They say approaches up to now have failed because they make incorrect assumptions about why adolescents use drugs. They feel giving information or trying to change values is a waste of time. Adolescents use drugs because of peer influence and they must team counter arguments or be inoculated against further use/abuse.
Specific sure-fire variables began to emerge in the literature around this time. Connell, Tumer, and Mason (1985) evaluated the School Health Education program in the U.S., a total health curriculum that involved 30,000 children in 20 states. As usual, they found knowledge gains, but also some increases in attitudes and self-reported skills and practices. These latter increases correlated with the number of classroom hours committed to the program. The authors recommend 40-50 classroom hours necessary for effective changes.
Pickens (1985), in his review, suggested other variables that may contribute to program effectiveness: prior drugexperience of the target group;
teacher variables; and the developmental stage of the target group vis-a-vis drug use.
Tobler (1986) in her meta-analysis of 143 adolescent drug prevention programs found Peer programs most effective for the average adolescent and Alternative programs best for the "at risk" group. However, Bangert Drowns (1988), in his meta-analysis criticized Tobler's methodology and found most programs ineffective.
The SWRL Report (1988) on Prevention Goals, Methods and Outcomes found the Social Influence approach, particularly the "Just Say No" program, has limited effectiveness by itself, particularly with alcohol. The authors recommend prevention should start earlier than junior high and programs should aim to reduce underlying problems in drug users.
In 1989 Moskowitz published a large critical review of the research literature. He classifies most programs into one of three models: knowledge/attitude; values/decision making; and social competency and finds none very effective. Moskowitz says that with alcohol education it is difficult to articulate goals—is it abstinence or responsible use? Confusion also arises because there are minimum drinking age laws but most teenagers drink. With smoking education there is a clear message— abstinence. The present social climate is also ensuring the success of antismoking programs.
Reviews of smoking prevention studies reveal more successes than those in the area of alcohol education—probably for the reasons stated by Moskowitz. Flay (1985) reviewed 27 studies using psycho-social approaches to prevention and found serious methodological flaws in the research to date. He also found problems with assigning whole schools to experimental or control conditions since some schools have greater numbers of smokers than others. However, in spite of these limitations, he feels that programs based on the Social Influence approach can be successful some of the time, and that these programs have prevented further increases in smoking by up to 50% for up to three years. In 1985, Flay et al. also published the results of the Waterloo Smoking study. This program involved students from 22 matched schools in experimental and control conditions. The core program given in the first three months of grade 6 had three components: information elicited Socraticaloly from the students; development of skins to resist the social influence of family, peers and media to smoke; and decision-making skins and commitment not to smoke. Flay et al. (1985 ) found the curriculum affected the smoking onset process—particularly for those students already at risk.
Biglan et al. (1987) looked at a program teaching refusal slcills from the point of view of subject attrition and found that smokers dropped out of the treatment condition at higher rates than non-smokers. Therefore,
they concluded, it is hard to generalize the results of programs to those adolescents who are likely to become habitual smokers.
Two papers, one by Cleary, Hitchcock, Semmer, Flinchbaugh, and Pinney (1988) and one by Kozlowski, Coambs, Ferrence, and Adlaf (in press, 1989) criticize the effectiveness of the Social Influence model. I. Cleary et al. condude that such programs have small effects of uncertain '5 duration on smoking behavior. Kozlowski et al. argue for an integrated Al substance abuse program since smokers are also other non-medical drug abusers. They feel it is alright to impart information but don't try to change attitudes. Policy is probably more effective and less expensive in prevent ing smoking than much of the existing programming.
The history of successes of school-based drug education programs has not been a positive one. The general consensus appears to be that although there are individual successes, school-based drug education prevention ;programs, regardless of their underlying principles, have generally not proven themselves to be effective or are inconsistent in their effectiveness at best. Any positive effects from these programs, have been with respect to changes in knowledge. Changes in attitudes are not consistently found and positive changes in behavior are rarely found to be associated with these programs. We are left with the hope that this knowledge gain will ultimately be instrumental in changing attitudes and behavior, an assumptiontion that we cannot make with any degree of certainty (Goodstadt, 1989).
However, before we dismiss the benefits of school-based programming out of hand, we should re-examine two possibilities for the negative view espoused above—that problems of methodology and or a lack of integration of approaches may account for a lack of positive findings. Previously, we suggested that poorly designed studies that ask the wrong questions have been the reason for a lack of positive findings, and suggested that this may indeed be a poor excuse. However, the possibility exists that this is indeed an accurate statement. In fact, Milgram (1987), in the course of articulating a variety of potential reasons for the lack of positive findings, suggests that this may in fact happen with regularity. The potential reasons include the following: (i) the goals of the program may be non-specific making outcome assessment difficult; (ii) the program content may not meet student needs; (iii) teachers delivering the program may be untrained and or uncomfortable with the material; (iv) programs may not be lengthy enough to be effective; and (v) evaluations of these programs may not be conceived properly so that the right questions are not asked. Some of these are problems associated with the program and others are problems of evaluation design. While all are possible, it seems unlikely that methodological issues are high on the list of possibilities.
Increased attention to evaluation issues in the literature recently should haver reduced the possibility of this being proposed of poor evaluations accounting for failure. The fact that it is still being proposed suggests that the problem lies with the products and not the method of evaluation.
Goodstadt (1988), rather than focusing on the negative findings, takes a constructive approach and proposes that the problem is that these programs which focus on the individual student may be insufficient in themselves. There is a need for both drug education and drug policies to prevent use/abuse. The implication is that education by itself may not be sufficient, but that it requires a policy component to complement it which acknowledges and reinforces the messages in the drug education component and at the same time recognizes the large number of students who do not use or abuse drugs.
The most recent educational thrusts have taken such an inintegrated approach and built the two components into school system interventions. The concept of integration is the cornerstone of the Addiction Research Foundation's program thrust in the school system. It acknowledges that the issue of alcohol and drugs must be dealt with in a comprehensive manner.
It suggests a coordinated curriculum component ideally running from kindergarten to grade 12, and one which involves a number of courses. It incorporates strategies for early identification which will help those beginning to be at risk, and proposes a policy component which specifies the rules for students and teachers and their obligations with respect to alcohol and drugs.
Implicit in the program is the acknowledgment that community support is integral to the program's success and other interventions, such as parenting programs, community campaigns are being designed to reinforce the messages in the schools and ensure that there is consistency. The success of this approach will be monitored and the years to come will determine its utility.
This document has intentionally taken a decidedly research oriented approach in the discussion of these school-based initiatives. We recognize and acknowledge at the outset that the subjective experiences of program developers and implementors may be different, but the objective criteria are the sole basis on which we are able to gauge program effectiveness. We also recognize that these findings generally represent short term interventions, and it is possible that the true value of these interventions may not be apparent for severe' years when their information and strategies may be more relevant.
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