Engaging Adolescents in the Fight Against Drug Abuse and Addiction: A Concept Mapping Approach

Abstract

Background.

To identify contextually-relevant strategies for reducing and eventually eliminating addiction, it is imperative to engage stakeholders that are most affected by drug abuse but typically left out of the conversation, such as adolescents.

Aim.

The aim of this study was to collaborate with 45 adolescent stakeholders participating in a school-based research program to identify areas to address addiction.

Methods.

Guided by a modified version of the mixed-methods concept mapping approach, adolescents were asked to brainstorm and sort a list of statements about how to address addiction in their community. The data were then analyzed via multidimensional scaling and hierarchical cluster analysis.

Results.

The concept map identified eight clusters from 75 edited statements: policing/security (e.g., increase punishment for selling drugs), helping community (e.g., create more jobs), treatment (e.g., make treatments more affordable), increased awareness (e.g., identify and help at-risk youth), communication (e.g., more communication with people who are abusing drugs), increased understanding/education (e.g., online communities for people who are abusing drugs), clean up community (e.g., clean up abandoned houses) and prevent addiction (e.g., effectively deal with peer pressure).

Discussion.

These stakeholder-driven ideas are consistent with the socioecological framework of addressing substance use and add to the credibility and transferability of individual and systemic level approaches to reducing substance use in marginalized communities.

Conclusion.

This study emphasizes the feasibility of engaging adolescents in the development of contextually-relevant addiction education, prevention, and treatment interventions in underserved communities.

Introduction

Substance abuse is a significant public health problem that causes considerable harm to individuals, families, and societies (Henry & Augustyn, 2017; Solis et al., 2012). Alcohol and other psychoactive drug use is associated with population-wide negative health impacts, such as violent behavior, psychiatric disorders, risky sexual behaviors, neurological impairment, and adverse health effects linked to prenatal drug exposure (Bassey et al., 2018; Bosma-Bleeker & Blaauw, 2018; Vaiserman, 2013; Yang et al., 2018). Furthermore, over 72,000 Americans died from drug overdoses in 2017, including the use of illicit drugs and the misuse of prescription opioids, representing a two-fold increase within the past decade (National Center for Health Statistics, Centers for Disease Control and Prevention, 2018). Given the significant direct and indirect effects, addiction can have not only on individuals but also on the many systems in which they live, it is important to engage multiple stakeholders in the fight against drug abuse and addiction, including adolescents.

A small but growing number of studies have demonstrated the promise and benefits of partnering with adolescents in understanding and developing interventions for health-related issues, such as obesity (Livingood et al., 2017), HIV/AIDS (Marcus et al., 2004) and mental health (Mance et al., 2010). In a study aimed to develop strategies to prevent youth substance use in a rural county (Kulbok et al., 2015), adolescents partnered with parents, community leaders, and research specialists to develop and implement a substance abuse prevention program. In addition to developing and implementing a contextually-relevant substance use prevention program in the community, adolescents in the study also reported high levels of enthusiasm about the project, experiences of authentic leadership, development of research skills, and a closer connection to their community (Kulbok et al., 2015). Adolescents are directly and/or indirectly affected by health-related issues, such as substance use, and are uniquely situated to benefit from and participate in research that informs the prevention and treatment of health conditions. It is especially important to involve the voices of marginalized adolescents to expand the reach of health-related strategies and interventions (Israel et al., 2005; Ozer, 2016). One powerful, yet underutilized, tool for identifying and prioritizing ideas generated by adolescents and other stakeholders is concept mapping (CM).

CM is a stakeholder-driven mixed-methods participatory research approach that is well suited to identify community-level health-related issues (Vaughn et al., 2017; Vaughn & McLinden, 2016). CM has been widely used for health research among adults (e.g., Donaldson et al., 2019; Mead et al., 2018; Szaflarski et al., 2015; Weinstein et al., 2015) or to identify issues of importance for youth (e.g., Snider et al., 2010; Vaughn et al., 2013) but to a lesser extent, with adolescents directly (e.g., Bayer et al., 2010; Dare & Nowicki, 2019). Although limited in number, studies have demonstrated promise in using CM with adolescents to identify solutions to public health issues, such as sexually transmitted infections (Ewan et al., 2016) and decision-making regarding breastfeeding (Nuampa et al., 2018). These studies highlight the feasibility of using CM with adolescents, as well as the ability of CM to improve the “translational capacity” of health research (Sangalang et al., 2015) and improve health outcomes by incorporating prevention and treatment strategies that are based on the lived experiences of adolescents (Reich et al., 2015). The proposed study will extend the literature by using a modified version of CM to examine adolescents’ contextually and culturally relevant ideas for addressing drug abuse and addiction in underserved rural and urban communities in the Midwest of the United States.

Materials and Methods

Study Setting/Participants

Students in the current study were participants in Youth Built Change, a National Institutes of Health-funded pipeline program aimed to increase student’s intrinsic motivation to pursue Science, Technology, Engineering and Mathematics (STEM) research and highlight the relevance of STEM skills to one’s own personal life and community over the course of an academic year. Each year, approximately four teachers and 50 students will be recruited from one urban school and one rural school in the Midwest. Throughout the course of the program, teachers and research staff will work directly with students to design and implement addiction-related community-based research projects. At the beginning of each year, students and teachers will be required to attend a day-long research kick-off event at a local university with research staff. For the purposes of the current study, data were used from the cohort of students who attended the first annual Research Kick-Off event of the program. During the Research Kick-Off event, students were introduced to community-based participatory research by setting the stage for students as co-researchers in the investigation into drug abuse and addiction in their own communities via CM.

The research team introduced the program and study to 10th-grade students at one urban school and one rural school in the Midwest. Interested students were encouraged to apply for the program. The students who were selected for the program demonstrated an interest in reducing/eliminating drug abuse or addiction, working in teams or intellectual curiosity. Students who were chosen from the applicant pool were invited to attend a meeting with their parents to discuss the program. Consent was collected from parents and assent from youth at the meeting. Following this meeting, students and teachers were invited to the Research Kick-Off Event at a local university. Data collection for the current study took place during the event and was approved by the University of Cincinnati Institutional Review Board.

CM Procedures

This study used a modified version of CM methodology as described by Trochim and Kane (2005), consisting of six steps: (a) identifying the prompt, (b) generating ideas, (c) editing ideas, (d) statement sorting and rating, (e) data analysis, and (f) utilization. In Steps 1–2, adolescents were asked to generate statements in response to a prompt regarding how best to address drug abuse and addiction in their community. In steps 3-5, the statements were edited for clarity and relevancy by researchers, sorted by adolescents, and analyzed via multidimensional scaling (MDS) and hierarchical cluster analysis (HCA). As discussed further below, adolescents were not asked to rate the importance of generated statements and the full range of CM metrics was not used, as conducted in other CM studies (Ewan et al., 2016; Nuampa et al., 2018). The data were provided in real time and were used to guide action planning for reducing addiction in adolescents’ local communities.

Steps 1 and 2: Identifying Prompt and Idea Generation.

Adolescents were asked to provide at least three ideas in response to the prompt, “I believe that the thing we should be doing about drug abuse and addiction in my community is….” Each participant entered their individual ideas into a tablet provided by the research team. Participants were not able to see the ideas that were contributed by others during the brainstorming session.

Step 3: Editing Ideas.

To represent the diversity of ideas and minimize the response burden for the sorting step, researchers entered the statements into Excel file and edited for grammar and clarity of expression without altering the original response meaning. The research team reviewed and discussed all statements and agreed upon the final list of statements. The discussion consisted of identifying the statements that best captured all of the generated ideas, ensuring that none of the statements were repetitive and that the original meaning of all statements was retained. Prior CM studies recommend a final list of <100 statements after editing to accurately depict the diversity of ideas (Kane & Trochim, 2007).

Step 4: Statement Sorting.

Using online card-sorting software (Optimal Workshop) on a tablet provided by the research team, adolescents received a link to a data collection platform which included a virtual set of cards containing the statements. Each card contained one unique statement. Adolescents were instructed to electronically sort the cards into as many or few categories as they felt appropriate and give each category a name (label). The adolescents were also told that each card could only be sorted into one group and that every group had to have at least one item within it. The research team specifically instructed the students NOT to have “other” or “miscellaneous” categories and also made themselves available to answer questions and remind students of sorting instructions during the in-person task. Adolescents were instructed to complete this task independently. After the task was completed, the research team reviewed the sorting data to ensure that instructions were followed. Results from the sorting task were then transferred to open-source software in R (McLinden, 2018). The CM process was conducted as part of a larger 1-day event, thereby limiting the ability of adolescents to rate the importance of the statements. This extra step was removed from the methodological process in this study due to the need to provide real-time feedback on the day of the event.

Steps 5 and 6: Data Analysis and Utilization.

Concept maps were created via MDS and HCA in R (R CoreTeam, 2013). MDS converted the sorting data into a two-dimensional visual representation, with each idea represented as a point on the map. We calculated a stress value to measure the goodness of fit of the point map to the sorting data. A stress value <0.39 is considered acceptable (Sturrock & Rocha, 2000). To partition the map of all ideas into a smaller set of clusters of related ideas, HCA was applied to the x- and y-coordinates. Proximity of points indicated the degree of similarity, such that points close to each other on the map represented similar ideas from the perspective of participants, while points that were further away from each other depicted ideas that were seen as different and were rarely sorted together. HCA analyses were used to examine how the points (i.e., ideas) clustered into ideas or themes. The goal of this process was to accurately capture and describe all of the ideas in the map with as few clusters as possible (Vaughn & McLinden, 2016). The research team reviewed multiple cluster solutions to determine the appropriate number of clusters (cluster analyses yield multiple solutions that can range from 1 to the total number of ideas). A final step was to create a label for each cluster that succinctly expressed the theme for a cluster while remaining grounded in the meaning provided by adolescents. As such, the research team reviewed the labels used by adolescents in the sorting process as a guide for creating final names for the clusters. The clusters were used to identify solutions to reduce addiction in the adolescents’ local communities.

Results

Participants

Participants included a sample of 45 high school students in grade 10 from one urban school and one rural school in the Midwest. In the urban school, the student population was 98% African American and 87% economically disadvantaged. The rural school had an Appalachian study body for whom 99% of the families fall below the poverty line and 98% were White. Students ranged in age from 15 to 16, were 76% female and from a range of racial/ethnic backgrounds (60% White [n = 27], 25% African American or Black [n = 11], 7% Asian [n = 3], 4% Mixed Race [n = 3]), and 4% Hispanic/Latino [n = 2]).

Ideas for Addressing Addiction (Steps 1–3)

Adolescents provided a total of 162 responses to the prompt. After clarifying and editing for redundancy, a total of 75 statements were used in the sorting task.

Concept Map and Sorting Data (Steps 4 and 5)

Figure 1 displays the concept map, while Table 1 lists the reduced statements generated by adolescents. Items located close to one another were considered conceptually similar. For example, Items 1 (more cops and enforcement on drugs) and 58 (dogs should smell drugs sent through the postal system) were close to each other, suggesting that sorters found these ideas to be similar and sorted them together. In contrast, Items 48 (stop giving out Narcan because people [could] care less) and 53 (provide counseling to help people who receive Narcan) were located far apart, suggesting that sorters found limited similarity between items and sorted them separately.

Figure 1.

Point and cluster map – adolescent-generated strategies to address addiction in communities.

Table 1.

Statements From Adolescents Regarding Addiction in their Community.

Policing/security
1	An actual police department; more cops and enforcement on drugs
9	More restrictions on the materials to make drugs
28	Parks need to be more secure and checked on because drug abuse happens too often in them
32	Stop the easy entry of drugs into schools
34	Put more restrictions on prescription drugs
36	Make laws and help the government realize that drugs are bad and ruining people’s lives
41	Choose not to legalize drugs because it increases drug usage in our community
42	Pinpoint where the drugs are coming from and who is supplying them
45	Have police officers check on neighborhoods (sections of homes)
58	For the postal system issue (drugs flooding the mail), dogs can smell out drugs by checking mail
62	Better patrol in communities to stop the selling of drugs
65	Increase punishment for selling drugs
69	Making it hard or impossible to be able to receive drugs
Helping community
2	Create more jobs
4	Sports activities that everyone will participate in
17	Get offices in town to where people can help others
22	More diverse community and more people that actually care about the community
46	Send home surveys of how households are doing
47	Build-up neighborhoods to be diverse (more people around to learn of others)
55	Providing jobs/housing/communities for people who are addicted and are coming out of treatment
70	More positive role models in the community
73	Help people with their financial issues
16	We need to add more activities in our town to distract people from doing drugs
Treatment
3	Adding new or expanding programs (D.A.R.E) to the community that help clean people and the communities
5	Increase availability of drug treatment programs
6	Create more support/anti-drug programs and groups
7	Have more places for people to go and get help
21	We need a closer rehab center because some people don't have any or they have to travel far
23	Provide different systems that allow people to interact with others that are open to the drug-world
31	Providing more opportunities to help people who abuse drugs
33	Improve treatment options and facilities for those struggling with addiction
35	Place more programs in communities that are poverty-ridden or overcome with economic struggles
39	Make treatments more affordable
44	Bring hospitals closer to where the majority of people are hurt due to drugs
49	I feel like we should hold more community events to keep people busy (and off drugs)
53	Providing the counseling that is needed to help people who receive Narcan injections in “field”
61	Have cheap or free counseling, a place that's easily accessible
Increased Awareness
8	More parenting in kids lives
14	Show everyone why living a clean and healthy life is the best thing possible
19	Positive role models; Be an example for others about how to be a leader, and not follow in the footsteps of someone who is doing drugs
26	Kids need to get away from their parents so they don’t follow in their footsteps
37	Identify and help youth who are at risk for drug use
43	Bring kids together into support groups if drug/alcohol abuse affects them or their family members
50	Effectively deal with peer pressure, don't hang around people who are involved with drugs
54	Parenting classes for people who give birth to addicted babies
57	Increased awareness about the side effects of drugs through media
63	Try to keep a well-balanced life, most people whose lives are crazy tend to lean on drugs as an outlet
64	Inform youth on what they're consuming or putting in their body
66	Spread awareness and let kids know that doing drugs is not ok
72	Teach our younger children to be more educated on drug abuse and how it affects not only you but others
75	Educate people on effects and possible outcomes of drugs instead of scaring them away without information
Communication
10	Talk more to the people around town about drug abuse and how it affects others
13	Communicate with people who are struggling with drug abuse and addiction
18	Communicate more with one another about the issue
20	Have more people who have been through situations with drugs, talk about their experience, and how it affected them
30	When approaching people be more calm and understanding (people who have experienced the same thing)
51	Starting the conversation with the community: students, teachers, coaches, parents, and businesses
Increased understanding/education
11	Make an online community for addicts
12	Have programs for kids who have parents that do drugs
24	Help people set their own personal goals to keep them from abusing drugs
25	We need to get where people can talk about their issues instead of doing drugs
38	Figure out a more effective way to help people who are addicted to drugs rather than arresting them
52	Giving families hope through programs, education, and support
60	Have a safe haven for people to come to vent and be free from worry
68	Providing comfort for suffering people, children, and families
74	Help people find solutions to their problems so they can stop using drugs or alcohol as an escape from those problems
Clean up community
15	Change the environment where drugs usually occur
27	Clean up the abandoned houses so they can't be used as drug houses
71	A clean-up crew to make the town not as sad, clean up trash, clean the street
Prevent addiction
29	Doctors should be more careful with prescriptions they give
40	Hold addicts accountable for staying clean and away from drugs
48	Stop giving out Narcan because people care less
56	Drug turn-in programs for prescription drugs that are leftover from surgeries, etc.
59	The federal government should run a program that takes convicted drug dealers/users into mandatory rehab
67	Not giving people so many pain killers at once when they have an injury or ailment

The stress value for the map was .24, which indicates a good fit to the sorting data. The research team reviewed multiple cluster solutions and decided on the eight-cluster solution because it balanced a sufficient number of clusters to capture the diversity of ideas and yet maintained a manageable level of detail. The eight-cluster solution provided distinct and sufficient details about each cluster without overlapping ideas. The eight clusters were “policing/security” (changes to drug laws or police departments), “helping community” (creating opportunities to prevent or reduce drug use in the community),“treatment” (ideas to improve access to or the quality of drug treatment), “increased awareness” (ideas to increase awareness about the impact of drugs),“communication” (ideas about improving messages and strategies about drug use), “increased understanding/education” (activities and topics that increase understanding and education in nontreatment settings about nondrug-related activities), “clean up community” (strategies to prevent and remove drugs from the community) and “prevent addiction” (peer and parental influences to prevent drug use.) Each of the items from each cluster are listed in Table 1. For example, one sample item from the policing/security cluster is “stop the easy entry of drugs into schools,” and one sample item from the cleanup community cluster is “clean up the abandoned houses so they can't be used as drug houses.”

Discussion

The intergenerational effects of addiction highlight the importance of engaging all who are directly or indirectly affected in identifying solutions to reduce and eventually eradicate addiction within families and communities. Drug addiction has been associated with several adverse health, social and legal consequences (Bassey et al., 2018; Kim & Park, 2019), especially in marginalized communities who are often disproportionately burdened with the costs of substance use (Friedman et al., 2016; J. Lee et al., 2018). When designing and providing drug abuse prevention and treatment interventions, it is important to engage the community throughout the process to improve the reach and effectiveness of public health efforts (Bermea et al., 2019; Sprague et al., 2020). Adolescent stakeholders in the current study identified eight areas that should be addressed within communities negatively affected by drug abuse and addiction: policing/security, helping the community, treatment, increased awareness, communication, increased understanding/education, clean up the community and prevent addiction.

The eight areas identified by adolescent stakeholders in this study are consistent with the socioecological framework of understanding substance use, in which individual and environmental factors influence the initiation and maintenance of use (Connell et al., 2010; J. O. Lee et al., 2017; Shahram et al., 2017). The identification of these areas by adolescents highlights their understanding of the complex interplay between the individual and environment in understanding, preventing, and treating substance use. At the individual level, adolescents stressed the need to improve drug education and treatment for those who use drugs in their communities. These recommendations emphasize the need for improvements in health care specifically in underserved urban and rural communities, as noted in the existing literature. For example, Bond Edmond and colleagues (2015) found that, relative to urban substance abuse treatment centers, rural centers had reduced access to highly educated counselors and offered fewer wraparound services. However, urban centers were less likely to offer specialized treatment options for adolescents. Other studies have also revealed a poorer quality of care, less access to care and more financial barriers in urban and rural treatment settings compared with suburban treatment settings (DeFlavio et al., 2015; Dew et al., 2007; Higgins et al., 2019; Hirchak & Murphy, 2017). There is a clear need to focus on removing barriers that affect the level of drug education and treatment provided within underserved rural and urban communities.

Community-level factors have also been shown to affect substance initiation and use, such as the quality of police-community relations. Adolescent stakeholders in the current study suggested that police departments should play a more active role in the community by checking in on individuals who use drugs, as well as engaging in more aggressive enforcement of rules and policies related to drug use. Previous studies have highlighted how police might be involved in addressing substance use within communities. For instance, The Champion Plan (TCP) is a program model in the suburban city of Brockton in Massachusetts that allows individuals who suffer from addiction to walk into the police station and ask for treatment (Varano et al., 2019). Preliminary findings from the program showed that 523 individuals walked into the police department 818 times asking for help during the first 24 months of operation. Individuals reported high levels of satisfaction with the program, as those seeking help were able to receive a placement bed within an average of 90 min of making contact with TCP staff. Similar culturally relevant programs might be implemented in underserved rural and urban communities, with a special focus on repairing the damaged relationship between police and some communities, particularly those concentrated in urban areas (Lyons, 2015; Rouhani et al., 2019; Schuck, 2019). Some police-based community models already exist for decreasing substance use in rural areas, such as the implementation of a naloxone prescription program in Lorain, Ohio in which trained police officers administered naloxone to suspected opioid overdose victims (Rando et al., 2015).

This study has several strengths, including the modified use of CM to engage adolescents in discussions regarding ideas to address addiction within their communities. As part of the larger National Institutes of Health-funded Youth Built Change project, adolescents had an opportunity to not only identify solutions as described in the current study but also design and carry out research projects that would directly address addiction within their community. This study engaged individuals who are traditionally left out of the research process, thereby increasing the translational capacity of research interventions in underserved rural and urban communities. Despite these strengths, a few limitations should be noted. First, adolescents did not have an opportunity to rate the importance of statements given the time-limited nature of the study. Future studies should include the ratings of importance from stakeholders to inform priority areas of focus and action within the community. However, it is important to note that despite the use of a modified version of CM, adolescents in the current study were engaged in the process and provided solutions that were consistent with evidence-based practices. Second, the full range of CM metrics was not calculated as part of this study. Future studies could provide additional measurements about the data, concept map and clusters such as bridging values. On a related note, in the current study, data were presented in real time on the same day that statements were generated, sorted, and analyzed. Future studies should consider both the subjective interpretations of clusters as well as the statistical output when selecting final decisions. The findings of the current study should be interpreted with caution given our limited use of CM metrics in this project. Third, this study included a small number of adolescents from two rural and urban communities in the Midwest. The findings are not generalizable to a broader population. However, this study demonstrates the utility of a modified version of CM in engaging adolescent populations in addiction research and highlights the alignment, and hence increased opportunities for partnership, between the ideas of scientific experts and adolescents.

Conclusion

The current study highlights the feasibility and importance of partnering with adolescents to increase their level of ownership and commitment to the goal of identifying solutions to addiction in their communities. Adolescents presented ideas consistent with the socioecological framework of substance use, thereby emphasizing the value of engaging adolescents in identifying potential solutions to health-related problems and in the co-design of individual, family, peer, and community-level interventions in marginalized communities (Hecht et al., 2018; Hidalgo et al., 2019). As stakeholders with lived experience in their communities, adolescents should have a voice and feel empowered in addressing this devastating public health concern. Adolescents in the current study identified eight important areas for reducing drug abuse and addiction. The intergenerational effects of drug abuse and addiction calls for nontraditional strategies involve the diverse perspectives of several stakeholders, such as marginalized adolescents. Findings from this study emphasize the importance of engaging adolescents in the fight against drug abuse and addiction, especially in marginalized communities who are often silenced in public health discourse on drug abuse and addiction.