The Science of Healthy Behavior

“I began my career here in the early ’70s working on a burn prevention research project,” recalls EDC Senior Vice President Cheryl Vince Whitman. “At that time, people believed that burns were not preventable—they just happened, and there was nothing you could do about them. Through public health research and epidemiological data showing the patterns of morbidity and mortality, we developed an understanding of effective prevention. We can prevent burns. We know that you can intervene in certain places to make a difference, and we began to understand exactly how to make a difference. For example, during a relatively short intervention period, we were able to demonstrate significant increases in parents’ knowledge of the risks that scalds and playing with matches pose to young children.”

Senior Scientist Susan Gallagher has seen similar progress in the field of injury prevention. “Twenty years ago, people laughed at me when I talked about the use of car seats for children as part of routine health care practice,” recalls Gallagher. “They said it would never happen.” In the two decades since then, she has seen the public health approach to injury prevention lead to car seat requirements for children nationwide. During those same years, many other injury prevention campaigns have also made significant improvements in the lives and health of Americans, young and old-the widespread adoption of bicycle helmets, seat belts, smoke detectors, and childproof medicine caps are just a few.

Today, these kinds of success stories provide the foundation for the growing field of prevention science—research-based strategies designed to promote health and safety. The prevention work of EDC’s Health and Human Development Programs spans the spectrum, addressing public health challenges related to alcohol, tobacco, and other drug use; HIV infection; injuries; and violence. We work with communities; schools; and state, local, and national agencies in both the United States and many other countries.

According to Vince Whitman, who oversees much of EDC’s prevention work in her role as director of HHD, the field is at a crossroads: “The whole field is in a different place than it was when I began. You can see the progress in the rates of violence and drug use among teenagers, which are going down despite a rise in the population of that age group. After these last few decades of research, we know a great deal about what works. However, the strategies that we know work need to be applied more consistently in schools and communities.”

Many HHD projects focus on closing the gap between research and practice by developing and disseminating research-based strategies to institutions and communities around the world. In this roundtable discussion, Dan Tobin discusses that challenge with Vince Whitman; Lydia O’Donnell, director of HHD’s Center for Research on High Risk Behaviors; Renée F. Wilson, who serves as director of several HHD projects that address the health and safety needs of urban African American and Latino youth; Michael Gilbreath, managing director of the Higher Education Center for Alcohol and Other Drug Prevention; and Deborah McLean, training and technical assistance manager for the Northeast Center for the Application of Prevention Technologies (CAPT).

Let’s start with a definition. What do we mean by a research-based strategy?

Deborah McLean: In community-based substance abuse prevention, a rich body of research has been amassed over the last 30 years, but especially in the last 10 years. We’re now at a point where we can identify about 140 “model” programs that have been evaluated.

In general, a program designated as “research-based” has been reviewed by a panel of experts who determine that the program meets a set of predetermined standards of empirical research-such as, the program is based on theory, has sound research methodology, and can show results that are clearly linked to the intervention itself and not to extraneous factors. However, one of the dilemmas we face is that different federal agencies use different standards to identify what they consider to be a “research-based” or “science-based” approach. Our funder, the Center for Substance Abuse Prevention [CSAP], identifies three categories of programs: effective, promising, and model. An effective programhas met a host of CSAP criteria, such as, it has been published in a peer-reviewed journal, or the intervention has been replicated or repeated in multiple settings and has shown a consistent, positive pattern of results. Promising programs meet fewer of those criteria. They may, for example, have produced positive results but haven’t been replicated yet in different settings. Model programs have been recognized as effective and have been developed by a group that has agreed to provide information, training, and technical assistance to communities that want to replicate these programs.

Michael Gilbreath: In the field of higher education, until recently, there has been little formal, rigorous research. There is now a growing body of work, including some of the work of the Higher Education Center [HEC], that does meet that standard. In the past, we’ve had to focus primarily on promising practices. Now, we are in a position to disseminate formal research results on the effectiveness of alcohol and drug prevention strategies specific to college campuses and college communities. That’s one of the key roles of HEC.

Cheryl Vince Whitman: I think we should draw a distinction between an effective strategy and a research-based strategy. There are a number of strategies that the field would generally say are effective, even without a formal, completed study. One example is the move in the last decade by all states to raise the legal age for alcohol sales to 21. During that same time period, we have seen a 40- percent reduction in traffic-related car fatalities involving people under 21. That’s a very significant reduction. Now, we can’t prove that the law is responsible for all of that reduction, but clearly the law has done a lot to stabilize the problem of drinking and driving by young people. And HEC builds on that strategy. We work with the campus community, police, and the local community to enforce age-21 laws and cut down on access and consumption.

Lydia, you have carried out a number of formal research projects. What is your definition of a research-based strategy?

Lydia O’Donnell: Prevention science is a relatively new field, in which we look at complex health and social issues. This kind of research is a lot messier than other kinds of research, such as research to see if the polio shot works or math scores improve. As a result, it has been difficult to identify what kinds of prevention strategies really work. But there are some things we do know-and we’re beginning to get that data out to the field. We’re at a point now where two strands of questions are coming together. The academic research community has been pursuing the question, How do we develop data-driven programs that are culturally relevant and produce measurable outcomes? At the same time, federal agencies are asking, What have we learned from the research base that we can share with schools and communities now—before opportunities are missed, before people die?

Renée Wilson: The agencies are also responding to questions from the field about how to make sense of all of these different programs. There was a time, not long ago, when people were just using whatever approach made sense to them. Now, with so many programs out there, the question becomes, How do I choose?

Demand

Why is everyone selling research-based strategies to schools and communities? And why do people want them? Is it a way to get grant money, or do they genuinely want something that works?

RW: I think it is more that they want something that works. In most cases, I’ve found that communities appreciate the expertise that is provided by researchers and evaluators. For instance, in the Reach for Health research study, schools received funding to set up a multifaceted health program that included a service learning program, and a health curriculum that addressed major issues for the community-violence, tobacco and other drug use, and early sexual risk taking. Working with schools, we were able to show that middle schoolers who participated in service learning were less likely to become involved in risky health behaviors. With those findings in hand, the study schools are expanding similar programs to reach even younger students.

I am also wondering what the research-based strategy is competing against. For example, I know that there have been studies of DARE that raise questions about its long-term effectiveness, and yet it is very popular. Maybe that’s because everyone wants to support the police department, or maybe it’s because it is easy to implement. If I’m a member of the school board or a community group, why not pick something easy? Doesn’t the complexity of some of the research-based strategies make them a tough sell?

MG: I think DARE is an interesting example. You’re right: It has been established in schools for many years, to the point where huge amounts of federal, state, and local resources go into funding it. But now there is so much interest in research-based outcomes—and so many questions raised through evaluations of DARE—that DARE has finally acknowledged that it has some problems. In fact, the Robert Wood Johnson Foundation is investing in revamping DARE in a way they hope will strengthen the program and produce positive results.

But let me go back to your question about demand. In the higher education field, the demand for programs comes from campuses looking for something that works. There is a sense of desperation. They want to go beyond the traditional alcohol awareness week or the “car wreck on the quad.” We try to help them focus their time and money on a collection of proven strategies.

CVW: From the school-based research we’ve done—both here and internationally—we know that the best approach in a school setting is a combination of two to four strategies supported by overarching health policy for the whole educational environment. Those strategies may include curriculum, community service, working with the local communities, and cutting down access. One research study says that if you take three or four strategies and target them toward a common goal in one setting, you are much more likely to make a difference than if you have one strategy, or if you have eight. If you go beyond three or four strategies, the program becomes diffuse and unfocused. You have to think about how to coordinate resources so that they work together toward a common goal, rather than competing with one another.

Fit: Replication vs. Adaptation

The issue of community resources is taking on increasing importance in the work of the CAPT. When we first started three years ago, many communities were contacting us, simply looking for a list of model, science-based prevention programs. As our work has evolved, we have developed a set of questions that encourage communities to look more deeply at the programs on the list. We use the list as a starting point for a conversation about a whole host of factors communities need to consider before selecting a program. For example, they need to look at the fit between the program requirements and their capacity to implement the program. Does the program complement existing programs? How will the target population react? Is the program sustainable?

LO: The fact that you are asking those questions is a major change in the landscape of prevention work. When I first came to EDC, nearly 20 years ago, funders were basically paying for the development of model programs. When a program was finished, there was this expectation that you put the word out and whoever wanted to use the program would get it and use it. It shouldn’t have been rocket science to realize that this wasn’t the case. People just don’t take packages from the shelves and use them. We’re seeing increased awareness around questions like, “What kind of infrastructure, support, training, technical assistance, and just plain cheerleading do communities need to adapt a program and make it their own?” And, “What do we really mean by ‘making it your own’? How many changes can a local community make to a program and still claim that ‘the program’ is effective?” Nobody knows the answer to that. That’s what makes it so difficult to identify effective programs.

DM: From my experience, researchers are failing to give communities enough guidance about how to take some components of a program out of the box, implement them, and test them. Where can communities make adaptations to a program without compromising the integrity of the program? What if the community can only afford to offer 15 workshops instead of 20? All kinds of compromises get made in order to implement the program in communities with cultural, political, and economic realities that may be different from the ones that existed in the controlled studies.

MG: Putting out good information or a model program doesn’t create change in and of itself. You also have to address the issue of resources and the environment in which the program will be implemented. In HEC, we take people who come out of health backgrounds, counseling backgrounds, and student services backgrounds and turn them into organizers and advocates for a different perspective. That requires figuring out how to get the president of the campus involved, how to get the community’s police department working with the campus police officers, etc.

CVW: Without that kind of community support, many proven strategies will not be effective. I’d like to bring up an example from a different setting. Several years ago, we worked with hospitals on a violence prevention program. We knew from our work in alcohol and tobacco abuse prevention that it can be effective to have physicians talk with patients about changing their behavior. The message, coming from an authority figure who has a relationship with the patient, can produce a change in behavior-provided that there is some ongoing support in the family and/or community. We took that same strategy to the arena of adolescent violence prevention. We worked with physicians in Boston who were treating adolescents, and we focused on their approach to routine visits with teenagers. We prepared trainings, materials, and protocols to motivate and equip health care providers to speak with their patients about their aggressive behaviors, such as taking weapons to schools or getting into fights. Physicians were willing to bring up the issues with their patients, but that was about all they could do. At the time, there weren’t programs in the community focused specifically on adolescent violence prevention, so they couldn’t make a referral. Out of that research, we developed the Boston Cares project, which has created a follow-up referral and support system in the community to help prevent injury and violence.

LO: Part of the role we play is to provide a two-way connection-both within schools and communities and between communities and funders. The funders have supplied millions of dollars for research and for resource centers to get these effective programs out to communities. In our roles, we are coming back to the funders and our research colleagues and reporting on what we’re hearing from communities. We are trying to broaden the conversation to take into account what it really means to adopt and adapt things at a local level.

Readiness

MG: One of the things we’re learning from schools and communities is that a lot of good approaches are still sitting unused on a shelf. It used to be a training manual sitting on a shelf. Now it is a task force on the shelf. That task force stops functioning if there is no ongoing dialogue about implementation, overcoming barriers, etc. We work with and prepare groups to assess and act on the information coming from the research community.

DM: It’s the age-old adage of beginning where schools and communities are at and moving them to where they want and need to be. If, for example, a community is about to implement a prevention program, then people will need help with the social marketing necessary to sell the benefits of the program to the community.

CVW: I would add another adage and that is the 80/20 rule: Unless you spend 80 percent of your time with the concerns of your ultimate users, you have only a 20 percent chance of succeeding. We also need to address the issue of organizational climate. We tend to focus on the characteristics of the community, but we also need to consider the characteristics of the agency implementing the program. Is the leadership fully committed to the program? Have they dedicated the time and resources to it? The organ-ization is the delivery agent. It’s like the needle for a vaccine: If the syringe doesn’t work, you can’t deliver the vaccine.

Overarching Approach

How similar does your work look across all the different domains you work in—substance abuse, violence prevention, injury prevention, HIV prevention? Is there a common approach to prevention across all of these domains?

DM: Based on our review of science-based programs, three keys to effective substance abuse prevention guide our work. The first key is encouraging schools and communities to use approaches that are based in theory and research. The second key is encouraging them to use multiple strategies in multiple settings, coordinated toward a common prevention goal. The final key is encouraging schools and communities to design and implement programs that take into account community resources as well as community needs. Can they carry out the program-including conducting a strong evaluation? Will they have the data to demonstrate whether their program is effective?

LO: It depends what kinds of projects you are talking about. For example, in our HIV prevention work with community-based organizations, the term “organizational development” doesn’t quite apply. They aren’t at that level.

DT: What do you mean?

LO: The school system you are working with is very likely going to be there for decades. The community organizations may not have that same assurance of longevity, or the same level of stability. They are more loosely organized. They have tremendous turnover in staff. If you go to a hospital or a clinic, you find much more infrastructure than you do with a community organization.

RW: I think that raises important questions for us about the selling of research-based strategies to these kinds of organizations. What can we do to provide them with the kind of assistance they will need while they are implementing a program? They may not be able to conduct research or continue with an evaluation.

CVW: All of our work addresses these environmental and resource issues while also focusing on the health of individual people. At the most basic level, all of our prevention work builds on some fundamental human desires. Every parent wants his or her child to succeed in reading, in math, in science so that the child will have opportunities later in life. All parents want their children to be safe and healthy. Nobody wants to lose a child in a car crash; nobody wants his or her child to become infected with HIV, or to have an unintended pregnancy. So the real argument for research-based prevention comes down to the human desire to keep children, adolescents, and adults healthy and able to learn and enjoy life. And that desire is shared by health practitioners, teachers, and police officers as well as parents. They all want to do things that make a difference in people’s health and well-being.