|
Dr. Backer, in your career, you have written about many topics, including “partnership and community change.” In your opinion, what initial steps should be taken by a community group to create lasting partnerships and promote community change around an issue such as preventing alcohol use among teenagers?
In developing any community partnership, people precede everything. Sometimes, a person or a small group of people aware of and concerned about whatever the topic is?some sort of environmental intervention?provides the initial leadership. Somebody has to take the first step, and an individual often does that. The leader is often very important in this kind of change process. Somebody must be willing to step up to the plate, say “I want to bring people together; I want our community to take action on this,” and take the first steps in mobilizing the energy for change. Sometimes, that person will have a particular intervention in mind. Sometimes, he or she sees a problem and may not have any particular clue about what sort of change would help to address it, but he or she knows there’s a problem. That’s the first step.
The second step is to have what is often called a “convening” of the community, bringing together people who have a stake in the problem, whatever it is. The term often used to describe those people is “stakeholders.” The people who come to the table need to be very carefully selected in terms of really representing the parts of the community that might have an interest in this particular problem or might be affected by it. What often happens in the deal to make a difference and try to solve a problem is that important players get left out. For instance, a number of environmental interventions we look at in our work together have an impact on small business people, store owners, and others in the community. If those people aren’t brought to the table, they may later resist the change that’s brought about because they see it as possibly damaging them. Whether they are right about that or not is unimportant. If they think they are going to be damaged, they will resist the change, and that will lead to a bad outcome. This step deals with what the problem is, why solving it is important, what kinds of solutions might either be available or how to locate them, and finally, what the challenges and problems are and the reasons not to undertake what is being talked about with respect to some sort of change. That last part most often gets left out of the change process. People want to build a partnership because they are concerned with whatever the problem is and focus only on its upside. If we introduce this environmental intervention, then we’ll make great progress in solving the particular problem they want to address in our environment. Therefore, don’t look at the downside and the potential side effects that come with any intervention. The basic principle in public health is that any intervention, that has a powerful main effect, also has powerful side effects. If you acknowledge that up front, you are much likelier to succeed because you’ll have identified what some of the problems might be, and you can start working on how to avoid them. You won’t identify them all that way, but you will get some of them. The mindset that side effects are important and that they deserve attention also pays respect to the people involved in the change process.
The next step is to look at who needs to be involved in making the change happen and figuring out how to get them and their organizations directly motivated to participate. If you want me to be a part of the change process, you have to figure out what’s in it for me. Very often, that means what’s in it for me personally. For instance, if you can give recognition or potential for some sort of job advancement to people who are involved in the change effort, they’ll be much likelier to support it. Everybody may agree in theory that this intervention will help the community, but lots of things can help the community. If you want to get my attention regarding your intervention, you need to motivate me personally, and that usually means something that will be rewarding to me as an individual.
At the end of those preliminary steps, begin developing the partnership that will engineer the change, identify the intervention, and work within the community to get it installed. You want to be sure that those processes of building ownership and participation?looking at fears, resistance, and potential side effects?continue. You also want to look at the long-term future of the partnership once you’ve created it. Do you want it to go on forever or end on a specific date? Most partnerships aren’t intended to last forever. If it’s going to last, it may need to become its own organization at some point. Often, what starts out as a community coalition against drugs, violence, or whatever winds up being its own 501C3 nonprofit organization. That may be a great thing to do, but it is then a different kind of organization, and you need to look at issues of sustainability. If you go in that direction, the organization is going to need some money. Where is that money going to come from?
Many of the community groups using this site will have “information dissemination” as a key component of their prevention programs. What vehicles of information dissemination have you found to be most effective, and why?
The most effective information dissemination vehicles are people. Interpersonal contact of either a formal or informal nature where people talk to people, especially people the community wants to listen to, is vital. Journalist Malcolm Gladwell, in his book The Tipping Point, talks about “meaning mavens.” That’s his fancy term for people in a community others look to for their opinions. It isn’t necessarily that the people will follow blindly whatever they say, but these are persons whose opinions are valued and who help determine what a community needs in setting forth on different kinds of social interventions, like drug abuse or prevention. That’s where the term comes from. Anyway, whether you call them meaning mavens or not, these key persons in a community are listened to by other people. If you can get them to disseminate the information you want to put across, that’s the most effective process. Dissemination is a person-to-person operation. Print materials you put out can support that information. If print materials are used, the simpler and easier to read, the better. The shorter, the better. If they’re Internet-based, as many things are today, that’s good, too. Again, short and simple is better than very complicated, particularly when you are dealing with people in communities who have economic challenges. Even though someone might have a computer, it might be an old computer, and if you’ve got very graphically complex materials… We had some debate about this at the beginning of this project. People with old and not very powerful computers may not be able to download files, or it will take so long that they’ll give up.
Information dissemination is first a personal process. You want to get people talking to each other. You especially want key people in the community whom others respect and value to help disseminate information, and you want to support that process with print materials and Internet-based information that is as simple, direct, and short as you can make it. One of the problems in all elements of information dissemination is that people are already overwhelmed with information, and the quicker and easier you make it for them to consume the information you want them to have, the more likely it is to have impact.
The next question I have gets into a little bit more about assessing community readiness to change. As we discuss in the Resource Guide available on this Website, assessing community readiness to change is a key step in preparing to implement any environmental strategy. Could you talk a little bit about some of the best ways to assess community readiness for change, and why this may be important?
The process I described for building a partnership, convening people, and bringing them to the table is the best way to do that. Again, people need to look openly at the question, “Why isn’t the community ready to change?” In most change efforts, too much attention is devoted to looking at the positives. People are inclined to downplay the negatives because they fear that if they look at the negative stuff, the change won’t happen at all. My experience in research on this subject suggests that just the reverse is true. The more you ignore the potential downside?the negative aspects or lack of readiness in this case?the more likely the change effort is to fail. Take people to the table and ask them these questions: Are we ready to undertake this change? What are the positives? What are the ways in which our community is ready? Examples of positive factors are that we want to do this and that we think drug abuse is an important problem among our kids. Those are elements of readiness. Elements of lack of readiness are that another drug abuse prevention program recently was a terrible failure, or there are 10 other issues right now. For example, right now in this country and to a certain extent the world, other things have been put on the back burner because of the terrible events of September 11th. Everybody knows that life has to go on, but it is hard to get a perspective on a change that you think is less urgent than what may be necessary to deal with. If you’re in an area affected by what happens in New York City or the neighborhoods near the Pentagon, change is taking on a different dimension. In one case, we worked in a community called Grand Forks, North Dakota. A devastating flood put much of the city under water in 1997. That changed everything. Even now, people still have to look at other change efforts in light of the recovery process that 4 years later is still going on.
Dealing with readiness means bringing people to the table, asking them to look both at why we’re ready and why we aren’t ready, then developing some sort of plan to deal with the elements of unreadiness, so to speak, either by delaying the change effort or figuring out some way to increase the level of readiness through talking with people about why they feel a lack of readiness to make the change. What it often comes down to is that people think the change is important, but they fear they will fail if they undertake the intervention. Readiness is not just feeling it is important to change, but also feeling you are able to do so. Those are the two main components of readiness.
An intervention is often built around helping a community learn more about how the people can mobilize their resources to make the change so they feel there is some reasonable likelihood that they will succeed. If you feel certain you’re going to fail in the change effort, why would you undertake it?even if you think it’s really needed?
The next question deals with work you’ve done on issues of fidelity and adaptation. Can you explain what these two terms mean and why these issues may be important to groups trying to implement prevention programs?
Anytime a program has been subjected to scientific research to prove whether or not it works, finding a balance between program fidelity and adaptation becomes an issue. In a year-long study we did for the National Center for the Advancement of Prevention, we learned that when good, science-based prevention programs get implemented in new settings, a balance must be found between fidelity?adherence to the particular structures, activities, and guidelines by which the program was developed?and adaptation?changing the program to reflect different community needs, wants, or circumstances. It can be difficult to remain faithful enough to the original design that you don’t compromise its ability to do whatever it does, particularly with science-based programs. To be effective, some programs need to be followed fairly precisely, or you lose what the science has proved will work. At the same time, adaptation is almost always necessary because communities differ, circumstances differ, and budgets differ. It may be that you simply don’t have the money to implement all parts of a program, so you have to make a decision?unless you are going to not use the program at all. What parts of it are the minimum you need to put into place to have reasonable fidelity, and how much can you adapt to change the original program to fit local needs?
Use of media campaigns has become a key component of many prevention programs. What are some of the “new” media approaches being used today in prevention programs?
Most of the new media and prevention programs, or any other area in health communication, have something to do with the Internet. In many cases, what’s newest and most innovative is an approach that balances interpersonal contacts and something Internet-based. The Internet is wonderful for conveying information, but it’s not so good for persuading people to change or helping them deal with the problems related to change. The key ingredient, whether in a communication campaign or something else, is that the health communication campaigns of all sorts that are most likely to succeed are the ones with multiple components and involve interpersonal action at the community level, as well as some large-scale information dissemination, some of which now gets done via the Internet. This is not really new. For 20 years now, research has shown this. If you can balance the different aspects of the campaign so that you have people contact where that’s necessary and information easily available on the Internet for those who can get to it, that’s most likely to be successful.
Do you know of any prevention-related media campaigns that have been successful? If so, which ones do you believe have been successful, and why?
Lots and lots and lots of examples could be given, so I’ll try to narrow it down just to a couple. One that has had a lot of public interest in the past couple of years is the Florida Truth Campaign, which is the tobacco prevention campaign in the State of Florida. I think what’s most distinctive about it is that it had a high level of youth involvement in designing and carrying out the campaign. This reflects the trend in the youth development field that is sometimes referred to as youth involvement or youth governance. Basically, the idea is that services for kids ought to be directed by the kids who are being served. One of the things that has made this campaign successful and one of the things that’s made it controversial is that it is, to a significant extent, run by kids. Another program that also has kid-oriented influence is HealthRocks! This program is conducted by the National 4-H Council and uses local 4-H clubs as vehicles for promoting tobacco use prevention, primarily among middle school kids. That is also a youth-directed campaign. Those are two examples I think of right away. A third one that’s an old campaign but one I think has a lot of lessons people can learn from in the environmental area is called the Stanford (as in Stanford University) Five City Heart Disease Prevention Project. A lot of research indicates that this very famous campaign has been successful in helping communities primarily in Northern California around the area of Stanford University prevent heart disease by involving whole communities?churches, community groups, supermarkets, and employers?and all kinds of community institutions and groups in the making of this campaign. The research on it says that that community involvement is key to its success. Of course, you can see the common thread in these three campaigns. Whoever is going to be affected by the campaign has to be involved in designing it and carrying it out. That’s one of the most powerful tools for success, and unfortunately, it gets missed a lot in campaign design.
That leads into my next question: What advice would you give to a community coalition trying to start a media campaign around a substance abuse issue?
Whoever the campaign is directed to, get those people involved in designing it and carrying it out. Second, consider how the media campaign will fit into other things going on to prevent drug abuse with the target population. Honestly, the third thing is to have modest expectations of what the media campaign can produce. One reason health communication campaigns in general have a bad reputation in this country is that we sometimes have quite unrealistic expectations about how much they can do. They can be successful. They can justify the investments made in them, but in the end, they are unlikely to make big increases in preventing whatever kinds of behaviors they’re directed to because so many of the levers for behavior change aren’t available to something that’s based in the media. Once again, you really have to get back to interpersonal, one-on-one interaction that’s not media-based to have greater influence in changing behavior.
When evaluating a completed media campaign, what would you have a community look for regarding the effectiveness of that campaign?
The goal for evaluation is behavior change, but that is often very difficult to come by without having a tremendous amount of money available. To try and figure out whether or not the campaign has changed behavior, get together a group of community leaders and key informants in the community to talk about what difference it has made and use their input or to go out in the community and get some good case examples that will at least give some insight about individual cases of change. I think those two approaches have the greatest value. If the resources are there to do a more formal evaluation, that can obviously be very useful. But that is an enormously expensive operation, and most communities simply don’t have the money to do that. Instead, use a community process that brings the community together and a case example process that goes out into the community and finds some examples of success. As I have said in answering several of the previous questions, at the same time, take a deliberate look for what didn’t work, examples of ways in which the program failed, which can be particularly important in figuring out how to make it operate better in the future.
My last question is more general and related to environmental strategy. What environmental strategies have you found to be the most successful in reducing abuse of alcohol, drugs, or tobacco, and what do you think are the reasons for that?
I have to put a little qualifier on this. In my own work either as a researcher or a community volunteer, I have not had a lot of direct experience with environmental intervention. My work has been in other areas. Still, I can make one statement from observation and familiarity with the knowledge base about what works and what doesn’t in creating change in communities. The environmental strategies that work the best?and this is true for all other kinds of substance abuse prevention strategies?are the ones that have been thoughtfully and creatively integrated into the community’s total response to the issue of substance abuse prevention. Environmental interventions don’t have as much potential to have some impact in the community if they are isolated. They should be woven into other kinds of strategies and other kinds of institutions to provide more opportunities for leverage and partnerships with other players than the ones who are involved directly in the environmental intervention. The more those elements of integration happen, the more likely it is that the intervention will be successful because that puts it in a larger complex. In case it isn’t obvious, the reason that is so important is because we’re trying to change very complex behaviors. To do that, we have to come at behavior change from as many different ways as we can. The cliché that applies here is: “The simple answer is that there is no simple answer.” To make things happen in any complicated arena of behavior, we will always fail if we look for simplistic solutions. Unfortunately, that’s what many people in the community are looking for, something quick and easy and simple to implement, and those approaches will always fail because they don’t address the complex behaviors that have to be changed for us to be successful.
|
