Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Drug Abuse Resistance Education: Another Failure of the Health Belief Model – Christopher McNicoll

Introduction
The school-based anti-drug abuse intervention, commonly known as D.A.R.E., fails to effectively reduce the incidence of youth drug abuse. DARE is not effective at reducing drug abuse in its target audience since it ignores social and behavioral principles. Even though the data suggests that the program does little to prevent the incidence of drug use, school districts expose millions of children to the program each year.

The use of illicit drugs by youth in the United States is a valid concern to parents, government agencies, and public health professionals. Past drug use has been linked with negative employment outcomes (2), and is the 9th actual cause of death in the United States (3, 4). In 2000, there were an estimated 17,000 deaths caused by illicit drug use, representing a decrease from 19,000 deaths in 1990. Yet drug use is still associated with increased risk of suicide, homicide, motor-vehicle injury, HIV infection, pneumonia, violence, mental illness, and hepatitis. (4) Clearly drug use warrants the attention of public health officials.

However, the illegality of drug abuse also attracts the ire of law enforcement. In 2003, 20% of those incarcerated in state prisons had been convicted on drug charges. Over 250,000 people served time in a state prison in 2003 for drug offense, compared to 262,000 for property crimes and 650,000 for violent crimes. (5) Thus, reducing the prevalence of drug use is a goal of those in criminal justice.

Since 1975, the Monitoring the Future Study has reported drug, alcohol, and tobacco use by 8th, 10th, and 12th graders. (1) In 2006, the study reported that 20.9% of 8th graders had used an illicit drug at least once in their life. This represents good news, as the trend in illicit drug use has steadily decreased since the 1996 peak of 31.2%. In fact, if this trend continues, lifetime drug use will surpass the all time low of 18.7% set in 1991. Data collected over the same time frame reflects the same trend for 10th and 12th graders. The decrease in drug use by adolescents is a cause for celebration among public health advocates, police departments, and policy makers. Yet which programs, or which people, are responsible for the decline in overall drug use?

To intelligently discuss the merits of DARE, we must first understand the environment in which it was developed. DARE is one part of the larger “War on Drugs” initiated during President Nixon’s tenure to counter the apparent surfeit of drugs in the United States at the time. The passage of the Control Substances Act of1970 created an agency within the Department of Justice that would later become the Drug Enforcement Agency. The executive branch has also operated the Office of National Drug Control Policy since 1988, whose director has cabinet-level status. In addition, public awareness campaigns such as “Just Say No” and “Above the Influence” have been promoted nationwide by the federal government since the early 1980s. In this anti-drug milieu, DARE was born.

From 1978 to 1992, Daryl Gates was the leader of the police department for the city of Los Angeles. Under his guidance, the LAPD developed the nation’s first Special Weapons and Tactics (S.W.A.T.) team and C.R.A.S.H. unit. In 1983, Chief Gates co-founded the non-profit organization DARE America, Inc. with a teacher from the Los Angeles Unified School District. In fact, the entire 17 week curriculum was developed by educators, not by the police. The goal was to stop drug abuse by teaching kids about the dangers of drugs before they ever tried them. (6)
According to DARE’s website, the program is used in 75% of the school districts in United States. Every U.S. state and territory, as well as 53 foreign countries, use the DARE curriculum. DARE is the most common anti-substance abuse program in American schools, and costs school districts millions of dollars each year. (11) While the curriculum has undergone some cosmetic changes in the past (most notably in 1994 and 2004), the basic format and goal is still the same. The change of 1994 mainly added tobacco and violence to the list of evils that children were taught to avoid. Unfortunately, there is not enough data to evaluate the “New DARE” curriculum of 2004, known as “Take Charge of Your Life.” However, it is safe to assume from the name that the new program does not depart markedly from the previous versions. Police officers still enter a classroom for one hour a week for 17 weeks, usually in the 6th, 7th, and 8th grades. The program still focuses on educating children about the risks of drug use, telling them how to make better decisions, and how to resist peer pressure. As stated on DARE’s website, DARE primarily focuses on “changing the attitudes and beliefs of adolescents regarding substance use.”

While DARE possesses a noble goal, it unfortunately is destined to fall short of meeting its objective. Even though drug abuse among youth has declined recently, DARE has not been a part of this decrease. Children that have graduated from the DARE program are no less likely to use drugs than children that did not have DARE. (7-9) We will leave the real reasons for the decrease in drug abuse for another time. In this paper, we will describe why D.A.R.E. is ineffective at reducing drug abuse in its target audience.

Neglects factors outside the Health Belief Model
From a policy perspective, the goal of DARE should be reducing harm from youth drug abuse. To achieve this goal, programs should aim to reduce the amount of drug abuse as well as the risky behavior that leads to abuse. DARE’s stated mission is “To provide children with the information and skills they need to avoid tobacco and alcohol, to live drug-free and violence-free lives.” Sadly, their approach to achieving their mission is flawed.

DARE assumes that education will eliminate drug abuse. This assumption is based in the Health Belief Model (prior to 1988), which states that when presented with the costs and benefits of a behavior, the person will make a rational decision. This decision will then directly result in a rational behavior. In social science jargon, the person considers the perceived severity of harm from the behavior, the perceived susceptibility to the harm, and the perceived benefits of the behavior. The individual also must decide if he can overcome the perceived barriers to adopting the new behavior. According to this theory, these are the only inputs that affect behavior. As applied to drug abuse, the theory states that if the children of America are abusing drugs, it is because they have made an uninformed choice. Clearly, if they had weighed the real benefits and costs of the behavior, the children would not have initiated the behavior. The logical solution is to change the perceptions of the youth so that they come to a different conclusion about the behavior.

The weakness of the Health Belief Model is apparent from this discussion. The theory accounts for only individual level factors, and neglects social causes of actions. It falsely assumes that with the right information, the desired outcome is guaranteed. Even prior to the creation of DARE, children knew that drugs were harmful. More education will not change the behavior of those susceptible, since they are already educated. In some cases, the youth actually overestimate the perceived severity of using drugs. Nevertheless, one-fifth of U.S. children still experiment with drugs.

The policymakers at DARE America are apparently unaware of this design flaw in the Health Belief Model. Even the new DARE curriculum of 2004 makes heavy use of the model. The four major areas of the new DARE lesson plans, as stated on the website, are to provide accurate information, teach students good decision making skills, show students how to recognize and resist peer pressure, and give ideas for positive alternatives to drug use. (6)

This approach can also be described as rational-empirical, which attempts to change human behavior simply by education. (10) Unfortunately, this model fails to account for social causes of behaviors. Perhaps the normative―re-educative approach would better suit DARE’s goal. In this model, the goal is to change social norms about a behavior, thereby persuading those susceptible to reject the behavior. This model is based on the belief that humans are social by nature, and are influenced by perceived social norms. (16) I believe that this model is better than a power-coercive approach as well. Since the youth have ideally not yet engaged in drug use, the degree of resistance to change is low. Also, this is a long-term strategy to reduce drug abuse by America’s youth, so changing social norms should be a realistic mission. By changing drug use from a ‘cool,’ rebellious act, we could reduce drug abuse more effectively.

We must remember that social factors cause kids to adopt behaviors. Children who feel neglected or develop personality disorders due to an unstable home life are more likely to abuse drugs. There has been recent evidence suggesting that adolescents who feel like they don’t “fit in” are also more likely to engage in risky behaviors, including drug use, alcohol use, and smoking. (1) In fact, this characteristic may explain why drug use is correlated with suicide, motor vehicle accidents, and other risky behavior outcomes described above. Therefore, supplying new information does nothing to counter these factors. Instead, we should try to eliminate the things that cause kids to feel like outsiders. If that is not possible, then we should at least label drug use as a behavior that is not correlated with rebellion.

Use of police officers encourages rebellion against DARE
The most recognizable part of DARE is the use of police officers as the educators for the DARE curriculum. Each police officer undergoes training by DARE America as a “School Resource Officer.” Common sense validates this approach, since police officers have a lot of experience dealing with illicit drugs. The officers are also engaging in community policing, which many activists support.

DARE fails to realize that drug abuse is a form of rebellion, and that the police officers are symbols of authority. Thus, using police officers may actually encourage children to abuse drugs. (12) As the anti-smoking Truth campaign so effectively proved, youth need a symbol of authority to rebel against. For the Truth campaign, the youth were motivated to rebel against the tobacco companies. In the DARE classrooms, the only symbol of authority is the police officer. Therefore, if a child wants to rebel, he may do so against the anti-drug social norms provided by the officer. This is especially true for communities and ethnic groups that have a pre-existing mistrust for the police department. Using police officers can be especially counter-productive if the target audience automatically ignores what the police officer says.
Additionally, DARE uses a power-coercive approach when a normative―re-educative approach is more appropriate. If adolescents feel like they are being told what to do, they resist that behavior as a way of showing autonomy and control. A more effective approach gives the adolescent a feeling of control and power, while subtly persuading him to believe that he is exercising his control by refusing to use drugs.

Ignores social context
The DARE program patronizes the students by encouraging them to “just say no.” DARE frames drug abuse as a behavior that will result in punishment, and simply implores kids to avoid the behavior. This highly individual-level approach ignores the social context of drug abuse. It also fails to properly educate students on what factors may lead to drug abuse, instead focusing on labeling the behavior as “bad.” As children and teenagers are looking for freedom and rebellion, this labeling may encourage them to abuse drugs.

The social network theory accounts for an important facet of adolescent behavior. The relationships and groups of friends that an adolescent nurtures affect how he behaves. This theory accounts for social norms, by explaining that people adopt a behavior based on the behaviors of those in their social circle. Thus, an adolescent is more likely to engage in drug use if the people in his social circle use drugs. Even if the kid knows the risks of drug use, and intends to avoid drugs, the social pressure will interfere with his intent. Fortunately, social network theory applies to the reverse situation too. Adolescents who felt that their social groups looked down upon drug use were less likely to use drugs. (1) The same association was not found for parental opinion. This exemplifies the importance of social circles, since peer groups had more impact than the parents.

Using the Health Belief Model does not account for external social factors, such as social norms, networks, and social modeling. In other words, DARE fails to account for all of the reasons that kids start using drugs. As stated above, a major cause of children engaging in risky behaviors is the turmoil of adolescence. Increasing a child’s decision making ability, or his knowledge of the harmful effects of drug use, will not change the turmoil that he is facing. The Health Belief Model that DARE follows is too simplistic, and does not account for the daily life stressors that increase the probability of drug use. The model also fails to account for the social constructs like ethnicity, which have been shown to affect drug use. (14)

Implications
There are several theories that DARE could be modeled upon to improve its efficacy. First of all, social control theory attempts to build stronger bonds with traditional aspects of the community. These stronger relationships with family, friends, and religion may motivate individuals to act in a more responsible manner. (15) The social norms of these traditional relationships will discourage drug use, and ideally lead to less youth drug use.

Similarly, social learning theory could be another method of reducing drug use by adolescents. This theory promotes the belief that behaviors are learned from watching others. Thus, if the adolescent did not learn the behavior from first-hand experience, he is unlikely to initiate the behavior. These two theories taken together suggest that a change in the environmental cues will change individual behavior.

Most importantly, the underlying social and cultural causes to drug use need to be changed if we want to reduce drug use. We need to use experimental evidence, based in social epidemiology, to discover true causes of drug abuse. Once these have been determined, we can implement a program based on evidence. It is possible that the best new program may not even be school-based. Regardless, it means that the DARE program needs to be completely revamped, or abandoned. However, DARE continues to have popularity, despite the fact that it has been proven to be ineffective. There may be other political reasons for the popularity of DARE that need to be dealt with as well.

Another important change that DARE should adopt is replacing the police officers with teachers, or possibly slightly older, former students. The educators also need to be more realistic with kids, and take a more normative-educative approach. Since the police represent a power-coercive approach, they hurt DARE’s mission.

The Los Angeles Unified School District abandoned DARE and adopted Project ALERT in 2005. Project ALERT represents a dramatic departure from DARE since it focuses on changing social norms, instead of just educating kids about the risks of drug use. (13) The RAND corporation has published extensively on the effectiveness of Project ALERT, and extols the curriculum for its competence of the social sciences. (17) This new curriculum has already been adopted in many school districts throughout the nation, and may eventually replace DARE.

Conclusion
Drug Abuse Resistance Education fails to reduce drug use in youth because it attempts to change behavior using an improper method. The Health Belief Model neglects the social factors that can influence a person’s decision about performing a behavior. DARE also improperly applies the power-coercive approach by using police officers as the instructors. Finally, DARE ignores the social networking theory and other social factors that lead adolescents to use drugs. By solely focusing on individual decision-making, and not changing social norms regarding drug use, DARE will not change the behavior of America’s youth. Some behaviors are amenable to change with increased information, but drug use is not one of those behaviors. Adolescents are already aware of the dangers of drug use, which sometimes is precisely the reason they use drugs. Drug abuse by adolescents is a behavior that necessitates widespread change of social norms to reduce the problem.

REFERENCES
(1) Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future national survey results on drug use, 1975-2006: Volume I, Secondary school students. Bethesda, MD: National Institute on Drug Abuse, 2007; NIH Publication No. 07-6205.

(2) Bryant RR, Jayawardhana A, Samaranayake VA, Wilhite A. The impact of alcohol and drug abuse on employment: A labor market study using the National Longitudinal Survey of Youth. Madison, WI: University of Wisconsin Institute for Research on Poverty / Institute for Research on Poverty Discussion Papers, 1992; No. 1092-6.

(3) Mokdad, AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004; 291:1238-1245.

(4) McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993; 270:2207-2212.

(5) Harrison PM, Beck AJ. Prisoners in 2005. Washington, DC: US Department of Justice / Bureau of Justice Statistics, 2006; p. 10, Table 14.

(6) D.A.R.E. www.dare.org/

(7) Lynam DR, Milich R, Zimmerman R, Novak SP, Logan TK, Martin C, Leukefeld C, Clayton R. Project DARE: No Effects at 10-Year Follow-Up. Journal of Consulting and Clinical Psychology 1999; 67(4): 590-3.

(8) West SL, O’Neal KK. Project D.A.R.E. Outcome Effectiveness Revisited. American Journal of Public Health. 2004; 94:1027–1029.

(9) Kanof ME. Youth Illicit Drug Use Prevention: DARE Long-Term Evaluations and Federal Efforts to Identify Effective Programs. Washington, DC: General Accounting Office, 2003; GAO-03-172R.

(10) Bennis WG, Benne KD, Chin R, Corey KE. The planning of change, 3rd ed. New York: Holt, Rinehart and Winston, 1976. pp. 22-45.

(11) Merill JC, Pinsky I, Killeya-Jones LA, Sloboda Z, Dilascio T. Substance abuse prevention infrastructure: a survey-based study of the organizational structure and function of the D.A.R.E. program. Substance Abuse Treatment, Prevention, and Policy 2006; 1(1): 25.

(12) Hammond A, Sloboda Z, Tonkin P, Stephens R, Teasdale B, Grey SF, Williams J. Do adolescents perceive police officers as credible instructors of substance abuse prevention programs? Health Education Research 2007.

(13) Orlando M, Ellickson PL, McCaffrey DF, Longshore DL. Mediation analysis of a school-based drug prevention program: effects of Project ALERT. Prevention Science 2005; 6(1): 35-46.

(14) Marsiglia FF, Kulis S, Hecht ML, Sills S. Ethnicity and ethnic identity as predictors of drug norms and drug use among preadolescents in the US Southwest. Substance Use & Misuse. 2004; 39(7):1061-94.

(15) Moos RH. Theory-based processes that promote the remission of substance use disorders. Clinical Psychology Review 2007; 27:537–551.

(16) Martens MP, Page JC, Mowry ES, Damann KM, Taylor KK, Cimini MD. Differences between actual and perceived student norms: an examination of alcohol use, drug use, and sexual behavior. Journal of American College Health; 2006; 54(5):295-300.(17) Ellickson PL. Preventing Adolescent Substance Use: Lessons from the Project ALERT Program (pp. 201-224). In: Crane J, ed. Social Programs That Work. New York: Russell Sage Foundation, 19

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