How do we create better outcomes for young people in American communities? Although the idea of community coalitions and collective action arose in the 1960s, there was a general lack of conceptual theory, epidemiological data, or empirical data to demonstrate that communities could come together and reduce the effects of individual and community risk factors and increase the well-being of young people until the 1990s.1 In spite of the early promise of community coalitions with respect to youth development, evaluations involving randomized comparison groups showed little impact.2 This may have been attributable to communities being fragmented in their responses to youth problems; specifically, community efforts overlapped, with agencies, schools, and local governments making uncoordinated decisions to fund programs that varied in quality, fidelity, and outcomes.
COMMUNITIES THAT CARE MODEL
A key aim in obtaining improved population health outcomes is developing effective community-wide models that lead to coordinated assessment, planning, and implementation of evidence-based programs and policies to replace the often duplicative and nonsystematic programming that commonly exists. With the involvement of multiple sectors and stakeholders, many believe that existing resources will be leveraged through coordination of action. Furthermore, because prevention science has matured over the past 20 years, there are now a large number of evidence-based programs designed to reduce youth risks and increase resilience.1 Until recently, no community-wide system or model of disseminating evidence-based programs to communities had shown success in cluster-randomized trials in sustaining positive outcomes in the domains of substance use, antisocial behavior, and delinquency.
Communities That Care (CTC) is a conceptual model that provides a clear, stepwise system for community stakeholders to form effective, coherent coalitions; assess resources and risk and protective factors in their community; choose specific empirically tested prevention programs focusing on identified risk and protective factors; implement evidence-based programs with fidelity; and assess the effectiveness of these programs after their establishment. By creating a “life cycle” of clear, focused actions for community coalitions and developing a roadmap for how to connect epidemiological data to interventions, CTC offers a systemic approach for collective action. As a result, the hope is that such a model can help communities focus their actions, use data for decision making, and implement tested models with the goal of developing more resilient and healthy youths.
COMMUNITY YOUTH DEVELOPMENT STUDY
In this issue of AJPH, Oesterle et al. (p. 659) present long-term findings from the Community Youth Development Study (CYDS), a carefully designed cluster-randomized trial. The study involved 24 small rural communities in 7 US states and followed more than 4400 youths from grade 5 through the age of 21 years. Because the communities conducted most of their interventions in early adolescence (grades 6–9), the age 21 data truly constituted a long-term follow-up into the transition to adulthood. According to the study findings, CTC communities showed a 49% reduction in initiation of gateway drug use among youths who had not already initiated substance use by early adolescence. Similarly, relative to control communities, there was an 18% reduction in new cases of antisocial behavior and an 11% reduction in self-reports of violent activities. These were overall effects, but the results were largely attributable to significant effects among young men, with few significant findings for young women. This gender-based difference is surprising given that base rates of substance use and antisocial behavior were very similar among male and female youths.
These findings further support earlier results from both the CYDS and a large CTC study conducted in Pennsylvania.2 Similar to the PROSPER model implemented via the Cooperative Extension Service,3 they demonstrate that, at least in rural communities, community coalitions that receive high-quality technical assistance can make substantial changes in the way they operate. That is, they can carefully choose and implement evidence-based interventions, implement these interventions with fidelity, and assess the outcomes to further improve their efforts.
POPULATION-BASED APPROACHES
The CYDS results are a strong demonstration of Geoffrey Rose’s assertion that population-based approaches are necessary because a majority of individuals who will later exhibit problems or morbidity will not be evident early in the developmental process.4,5 In other words, universal population-focused interventions can be effective because of their potential to reduce the risk of poor outcomes in the largest part of the population, those who do not show early risk. By conducting analyses with those who abstained and removing from analyses those who had already initiated early substance use, Oesterle et al. focused not on the highest-risk part of the population but instead on those who did not show early risk but later initiated use. Thus, the data amply illustrate Rose’s argument that universal prevention will likely reduce later cases by affecting the large majority of any population that is at relatively low risk.
Although the Oesterle et al. findings demonstrate effects on the majority of the population (not including the highest-risk group), it would be interesting if further analyses had been available that would have allowed a determination of whether early initiators in CTC communities were also affected through reductions in pathways to deeper behavioral health problems, including lower rates of addiction and arrest.
LOCAL PUBLIC HEALTH DEPARTMENTS
The Oesterle et al. findings allow a new level of optimism regarding the potential of communities to coalesce around a science-based approach to building community social capital that leads to improvements in community well-being. However, it is surprising that local public health departments have rarely taken on this task of installing and coordinating a science-based model for improving youth development and reducing community risk. Local public health departments should be encouraged to take on this role of coordination with schools, the juvenile justice system, courts, and agencies focused on family health and behavioral health. Such actions would support planning efforts required by local health departments for accreditation and can be coordinated with the activities of local and regional hospitals that are now required by the Internal Revenue Service to provide community benefits.
Footnotes
See also Oesterle et al., p. 659.
REFERENCES
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