Adolescent health and behavior problems continue to concern parents, the public, and policy makers. Substance abuse, violence, delinquency, and risky sexual behaviors damage lives. Treatment of these problems is costly (Harwood et al. 1999
Before 1980, there was little evidence that adolescent health and behavior problems could be reduced through preventive efforts (Berleman 1980
; Hansen 1992
; Tobler 1986
). Over the past 25 years, this situation has changed dramatically due to two advances in prevention science. First, longitudinal studies of development have identified risk and protective factors that predict these problems (Hawkins et al. 1992
). Prevention science postulates that negative health outcomes can be prevented by reducing or eliminating risk factors and enhancing protective factors in individuals and their environments during the course of development (Coie et al. 1993
; Mrazek et al. 2004
). Second, preventive interventions designed to reduce risk factors and bolster protective factors have been tested in controlled studies and have been found to be effective in preventing substance abuse, delinquency, and violence (Mihalic et al. 2004
; Weissberg et al. 2003
; Welsh and Farrington 2006
Interventions focused on preventing the initiation of substance use during early adolescence have shown prolonged effects in reducing the use and abuse of substances later in adolescence (Botvin et al. 1995
; Chou et al. 1998
; Spoth et al. 1999
). These results suggest that preventing the initiation of substance use during early adolescence by addressing risk and protective factors salient during this developmental period is a viable prevention approach.
Community coalitions have been suggested as mechanisms to build capacity to mount effective prevention initiatives in communities (Butterfoss et al. 1993
; Wandersman 2003
). Despite support for the development of coalitions to guide community prevention efforts, as illustrated by the federal Drug Free Communities Program, several studies have found coalitions to be ineffective in reducing the prevalence of adolescent health and behavior problems in communities (Hallfors et al. 2002
; Klerman et al. 2005
; Merzel and D’Afflitti 2003
Hallfors et al. (2002)
evaluated 12 coalitions funded under the Robert Wood Johnson Fighting Back Against Substance Abuse
initiative. They found that none of the coalitions reached their desired outcome of reduced youth or adult substance use. The editors of a special issue of the Journal of Adolescent Health
, reporting findings from the Center for Disease Control’s effort to use community coalitions to prevent teen pregnancy, described “serious reservations about a coalition-based approach to teen pregnancy prevention” (Klerman et al. 2005
, p. S117). They expressed concern that the coalitions studied were “comprised primarily of social service providers and … unable to reach consensus on supporting programs of proven efficacy” (Klerman et al. 2005
, p. S117).
Hallfors and her colleagues (2002)
suggested that community coalitions could produce better outcomes if three criteria were met. The coalitions (a) should have clearly defined, focused, and measurable goals and outcomes, with corresponding high-quality data sources to facilitate monitoring; (b) should be encouraged to use evidence-based programs, with careful attention to monitoring of both the dose and quality of programs provided; (c) should evaluate the programs implemented through coalition efforts using outcome measures meaningful to the community. At this time, it remains to be seen whether community coalitions can improve the quality of community prevention services to an extent that community goals for reducing risk, enhancing protection, and reducing the prevalence of adolescent health and behavior problems can be achieved.
Communities That Care (CTC) is an operating system that mobilizes community stakeholders to collaborate on the development and implementation of a science-based community prevention system. CTC meets and extends Hallfors’ and colleagues’ suggestions for improving coalition outcomes by providing structure, processes, and tools designed to enable coalitions to use prevention science as a basis for community prevention services. CTC provides a structure for engaging community stakeholders, a process for establishing a shared community vision, tools for assessing levels of risk and protection in communities, and processes for prioritizing risk and protective factors and setting specific, measureable community goals. CTC guides the coalition to create a strategic community prevention plan designed to address the community’s profile of risk and protection with tested, effective programs and to implement the chosen programs with fidelity. CTC instructs the coalition to monitor program implementation and to periodically reevaluate community levels of risk and protection and outcomes, and to make adjustments in prevention programming if indicated by the data (Hawkins et al. 2002
). CTC is installed in communities through a series of six training events delivered over the course of 6 to 12 months by certified CTC trainers. All CTC training materials are available on the internet at http://preventionplatform.samhsa.gov
Communities That Care is guided theoretically by the Social Development Model (SDM) (Catalano and Hawkins 1996
). The SDM posits that bonding to prosocial groups and individuals and clear standards for healthy behavior are protective factors that inhibit the development of problem behaviors. The SDM hypothesizes that bonding is created when people are provided opportunities to be involved in a social group like a coalition, family, or classroom, when they have the skills to participate in the social group, and when they are recognized for their contributions to the group.
This theoretical framework is applied in CTC in two ways. First, CTC encourages community stakeholders to adopt the SDM in their daily interactions with young people as a strategy for promoting healthy development. A goal in CTC communities is to ensure that all young people are provided developmentally appropriate opportunities, skills, and recognition, as well as healthy standards for behavior, by adults and organizations in the community.
Second, the social development model guides the community mobilization and training component of CTC itself. CTC seeks to create opportunities for all interested community stakeholders to participate in developing a shared vision for positive youth development based in prevention science. Through CTC trainings, diverse community representatives develop skills to work together effectively, thus increasing the likelihood that opportunities for interaction lead to rewarding experiences. The CTC process also suggests appropriate recognition activities to enhance the reinforcement of community board members for their participation in the process.
By increasing opportunities, skills, and recognition for community stakeholders to work together toward a shared vision, CTC seeks to develop social bonds among coalition members and a strong commitment to implementing effective preventive interventions with fidelity. Strong bonds and a commitment to science-based prevention are hypothesized to lead to greater collaboration among prevention service providers and community members, and high-quality implementation of the policies and programs initiated through CTC. When installed with fidelity, the tested preventive interventions should produce positive effects on risk, protection, and the prevalence of adolescent health and behavior problems in the community.
CTC’s model of community change incorporates theories of community competence (e.g., Eng and Parker 1990
), public health promotion (e.g., Bracht and Kingsbury 1990
; Butterfoss et al. 1993
), and prevention science (e.g., Coie et al. 1993
; Mrazek et al. 2004
). As shown in , it is hypothesized that CTC training and technical assistance will mobilize a prevention coalition comprised of diverse stakeholders and will increase coalition members’ shared commitment to using a science-based approach to prevention. The coalition also is expected to stimulate widespread adoption of science-based prevention among the community’s prevention service providers. This widespread adoption of a science-based approach is expected to increase collaboration on prevention efforts as stakeholders work to achieve shared goals of reducing prioritized risk factors and increasing prioritized protective factors. CTC also emphasizes the accountability of prevention services, including appropriate choice and implementation of tested, effective programs and policies with fidelity, and monitoring progress toward measurable objectives for community risk reduction and reduction of adolescent health and behavior problems.
Communities That Care Model of Community Change
This paper describes the aims, intervention, and design of a randomized controlled community trial of the Communities That Care system and investigates the baseline comparability of the 12 intervention and 12 control communities in the study in levels and trends in adolescent drug use and delinquency.