In the first randomized trial of Communities That Care (CTC), middle school students in towns that utilized the prevention system reported less delinquency, initiation of alcohol and tobacco use, and binge drinking than peers in comparison towns. Students in test towns also reported lower rates of current alcohol and smokeless tobacco use in the eighth grade.
CTC provides training and materials to help communities organize coalitions; identify risks for youth drug use and delinquency, as well as protective factors in the community; choose interventions with proven effectiveness; and implement the interventions with fidelity. Communities in Canada, the United Kingdom, the Netherlands, Germany, and Australia, as well as the United States, have adopted CTC. However, the current trial, called the Community Youth Development Study (CYDS), is the first to randomly assign communities to implement either CTC or prevention as usual. Earlier analyses of the data showed that CTC improved communities' coalition building, as well as their selection and implementation of evidence-based prevention programs. It also reduced the prevalence of factors associated with youth substance abuse. The new findings establish that CTC achieved its ultimate goal of preventing behaviors that pose a risk to health.
Training Communities in Prevention Science
The CTC program was designed by Drs. J. David Hawkins and Richard F. Catalano of the Social Development Research Group at the University of Washington. "We wanted to help communities use prevention science to guide their actions," explains Dr. Hawkins. "Prevention science tells us that if you want to prevent behaviors such as drug use, you need to address the risk factors for those behaviors in the community and strengthen protection in the community as well. Communities That Care provides stakeholders with tools to assess risk and protective factors in their communities, as well as a menu of tested and effective prevention strategies. Equipped with this information, they can map the profile of risks to which their kids are being exposed and select programs that best address those factors."
Participants in the recent study, which Dr. Hawkins led, were selected from 24 small towns in Colorado, Illinois, Kansas, Maine, Oregon, Utah, and Washington that had not yet implemented evidence-based prevention programs. The researchers randomly assigned half the towns to receive CTC training and implementation assistance and the rest to serve as prevention-as-usual controls. Six training sessions over the course of a year were provided to stakeholders in the CTC towns, including parents, teachers, law enforcement personnel, and other interested community members. The trainees identified the dominant risk factors for substance use in their communities, as well as protective factors they found lacking. They then chose two to five evidence-based prevention programs tailored to those risk factors from a list of tested and effective prevention policies and programs provided by CTC.
One CTC Community's Experience
"CTC provided a framework—a system, a set of steps—to help guide community-wide decisionmaking," explains Ms. Dalene Dutton, the executive director of the Five Town Communities That Care (CTC) program in Maine. "It led us through the process of how to find out what's really going on in our community, how to come together, and how to make decisions about what the community needs based on sound data and scientific principles."
One of the main risk factors identified by the coalition in the Five Town CTC program was the prevailing attitudes in the community, which did not discourage underage use of alcohol, tobacco, and other drugs. To address this risk factor, the Five Town CTC implemented an evidence-based prevention program, called Life Skills Training, in the schools. It teaches children ways to resist social pressures to smoke, drink, and use drugs. Compared with assessments before the program began, 35 percent fewer eighth-grade students reported perceiving laws and norms as favorable to drug use after completing the training.
"We also implemented other activities in the community to make sure that adults are communicating healthy beliefs and clear standards whenever they can," explains Ms. Dutton. "Once you make sure you have a program in place in the area of highest risk, CTC has you look for other places where you can also apply pressure in the community to reduce risk."
The reduction in risk will be much greater, Ms. Dutton says, if the kids get the message from the schools, their parents, their peers, and their church. "CTC allows you to have that stronger effect because you have a broad-based community coalition," she says.
The Five Town CTC also identified and bolstered protective factors for drug use, such as community recognition of socially positive activities. "Kids were telling us that adults were noticing when they were doing wrong but weren't really noticing when they were doing good things," says Ms. Dutton. To address this deficit, the community implemented a program called Skills Training and Recognition (STAR). STAR provides youth with the opportunity to learn new skills, gain recognition as they master the skills, and develop ties to places in the community where they can use their new skills. The researchers measured a 58 percent increase in community recognition of socially positive behavior in middle school students, as assessed by the student surveys.
"That's a really profound impact," says Ms. Dutton, "and we started seeing it soon after implementing the program."
A Webcast featuring communities that implemented the program in the Community Youth Development Study is available at archives.drugabuse.gov/newsroom/09/townhall.html.
Community-Wide Risk Reduction
At the start of the study, all fifth-grade students in the selected towns were invited to participate. The participants who contributed data to the study were 4,407 children from 88 schools whose parents consented to their participation. Of this group, 55 percent came from CTC communities and 45 percent from control communities. Just after joining the study and then annually through eighth grade, the students responded to a questionnaire about risk factors and behaviors. The grade 8 assessments occurred 2 years and 8 months after the CTC communities began the prevention programs that they had selected.
The results of the grade 8 student interviews revealed that since seventh grade, youths in the CTC communities were 32 percent less likely than those in the control towns to have begun using alcohol, 33 percent less likely to have smoked a first cigarette, and 33 percent less likely to have initiated use of smokeless tobacco. Students in CTC communities were also 25 percent less likely to have committed their first delinquent act between grades 7 and 8.
|CTC Intervention Group||Control Group|
|Used alcohol in past 30 days||16.4%||21.4%|
|Had five or more drinks in a row in the past 2 weeks||5.7%||9.0%|
|Used smokeless tobacco in past 30 days||2.2%||4.3%|
|Mean number of delinquent acts in past year||0.78%||1.13%|
In CTC communities, eighth-grade students were less likely to report having used alcohol or smokeless tobacco during the 30 days immediately before being interviewed or having participated in binge drinking during the past 2 weeks. CTC communities also experienced significant improvements in their targeted risk and protective factors.
"This study shows that a coalition of community stakeholders armed with tools solidly grounded in the advances in prevention science over the past 30 years can prevent kids from starting and continuing risky behaviors," says Dr. Hawkins.
"These results are very encouraging and support the theory that scaling up effective preventive programs in communities can improve outcomes for youth," says Dr. Belinda Sims of NIDA's Division of Epidemiology, Services and Prevention Research. "We know from other research that even though we have a number of evidence-based preventive interventions focused on drug abuse and related problems, the adoption and implementation of those interventions by communities still lag behind. Systems like CTC may help to reduce this research-to-practice gap."
"Community prevention programs work," says NIDA Director Dr. Nora D. Volkow. "We've also seen that they're cost-effective: For every dollar that is spent, you're going to save 5 to 10 dollars in consequences. But more important, you're going to gear the lives of young people to be successful."
To measure the sustainability of the effects of CTC, Dr. Hawkins and colleagues plan to track the participating youngsters from all 24 communities for 1 year beyond high school. They will also note whether the communities sustain their prevention programs and will examine the effects of ongoing efforts in the CTC communities on youth just entering the target grade levels.
The Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Prevention has made the CTC materials available for free (www.sdrg.org/ctcresource).
Hawkins, J.D., et al. Results of a type 2 translational research trial to prevent adolescent drug use and delinquency: A test of Communities That Care.Archives of Pediatrics & Adolescent Medicine 163 (9):789–798, 2009. [Full Text (PDF, 1.1MB)]